Surgical systems for generating three dimensional constructs of anatomical organs and coupling identified anatomical structures thereto

ABSTRACT

A surgical visualization system includes multiple light sources, at least one optical sensor, at least one display device, and a controller. The controller is configured to control at least one light source to illuminate surgical tissue in a first manner, and control the optical sensor to receive an image from the surgical tissue illuminated in the first manner. The controller calculates a three-dimensional image from the tissue illuminated in the first manner. The controller is configured to control at the least one light source to illuminate surgical tissue in a second manner, and control the optical sensor to receive an image from the surgical tissue illuminated in the second manner. The controller calculates one or more subsurface critical anatomic structures from the tissue illuminated in the second manner and combines the display of the three-dimensional image and the anatomic structures on the at least one display device.

CROSS-REFERENCE TO RELATED APPLICATION

This application is a continuation patent application claiming priorityunder 35 U.S.C. § 120 to U.S. patent application Ser. No. 16/729,751,titled SURGICAL SYSTEMS FOR GENERATING THREE DIMENSIONAL CONSTRUCTS OFANATOMICAL ORGANS AND COUPLING IDENTIFIED ANATOMICAL STRUCTURES THERETO,filed Dec. 30, 2019, the entire disclosure of which is herebyincorporated by reference herein.

BACKGROUND

Surgical systems often incorporate an imaging system, which can allowthe clinician(s) to view the surgical site and/or one or more portionsthereof on one or more displays such as a monitor, for example. Thedisplay(s) can be local and/or remote to a surgical theater. An imagingsystem can include a scope with a camera that views the surgical siteand transmits the view to a display that is viewable by a clinician.Scopes include, but are not limited to, arthroscopes, angioscopes,bronchoscopes, choledochoscopes, colonoscopes, cytoscopes,duodenoscopes, enteroscopes, esophagogastro-duodenoscopes(gastroscopes), endoscopes, laryngoscopes, nasopharyngo-neproscopes,sigmoidoscopes, thoracoscopes, ureteroscopes, and exoscopes. Imagingsystems can be limited by the information that they are able torecognize and/or convey to the clinician(s). For example, certainconcealed structures, physical contours, and/or dimensions within athree-dimensional space may be unrecognizable intraoperatively bycertain imaging systems. Additionally, certain imaging systems may beincapable of communicating and/or conveying certain information to theclinician(s) intraoperatively.

SUMMARY

In one general aspect, a surgical system for use in a surgical procedureis disclosed. The surgical system includes at least one imaging deviceand a control circuit configured to identify an anatomical organtargeted by the surgical procedure, generate a virtual three-dimensional(3D) construct of at least a portion of the anatomical organ based onvisualization data from the at least one imaging device, identifyanatomical structures relevant to the surgical procedure from thevisualization data from the at least one imaging device, couple theanatomical structures to the virtual 3D construct, and overlay onto thevirtual 3D construct a layout plan of the surgical procedure determinedbased on the anatomical structures.

In another general aspect, a surgical system for use with a surgicalinstrument in a surgical procedure is disclosed. The surgical systemincludes at least one imaging device and a control circuit configured toidentify an anatomical organ targeted by the surgical procedure,identify anatomical structures relevant to the surgical procedure fromvisualization data from the at least one imaging device, and proposesurgical resection paths for removing a portion of the anatomical organby the surgical instrument. The surgical resection paths are determinedbased on the anatomical structures.

In yet another general aspect, a surgical system for use with a surgicalinstrument in a surgical procedure is disclosed. The surgical systemcomprises at least one imaging device and a control circuit configuredto identify an anatomical organ targeted by the surgical procedure,identify anatomical structures relevant to the surgical procedure fromvisualization data from the at least one imaging device, propose asurgical resection path for removing a portion of the anatomical organby the surgical instrument, and modify the surgical resection pathduring the surgical procedure. The surgical resection path is determinedbased on the anatomical structures.

FIGURES

The novel features of the various aspects are set forth withparticularity in the appended claims. The described aspects, however,both as to organization and methods of operation, may be best understoodby reference to the following description, taken in conjunction with theaccompanying drawings in which:

FIG. 1 is a schematic of a surgical visualization system including animaging device and a surgical device, the surgical visualization systemconfigured to identify a critical structure below a tissue surface,according to at least one aspect of the present disclosure.

FIG. 2 is a schematic of a control system for a surgical visualizationsystem, according to at least one aspect of the present disclosure.

FIG. 2A illustrates a control circuit configured to control aspects of asurgical visualization system, according to at least one aspect of thepresent disclosure.

FIG. 2B illustrates a combinational logic circuit configured to controlaspects of a surgical visualization system, according to at least oneaspect of the present disclosure.

FIG. 2C illustrates a sequential logic circuit configured to controlaspects of a surgical visualization system, according to at least oneaspect of the present disclosure.

FIG. 3 is a schematic depicting triangularization between the surgicaldevice, the imaging device, and the critical structure of FIG. 1 todetermine a depth d_(A) of the critical structure below the tissuesurface, according to at least one aspect of the present disclosure.

FIG. 4 is a schematic of a surgical visualization system configured toidentify a critical structure below a tissue surface, wherein thesurgical visualization system includes a pulsed light source fordetermining a depth d_(A) of the critical structure below the tissuesurface, according to at least one aspect of the present disclosure.

FIG. 5 is a schematic of a surgical visualization system including animaging device and a surgical device, the surgical visualization systemconfigured to identify a critical structure below a tissue surface,according to at least one aspect of the present disclosure.

FIG. 6 is a schematic of a surgical visualization system including athree-dimensional camera, wherein the surgical visualization system isconfigured to identify a critical structure that is embedded withintissue, according to at least one aspect of the present disclosure.

FIGS. 7A and 7B are views of the critical structure taken by thethree-dimensional camera of FIG. 6 , in which FIG. 7A is a view from aleft-side lens of the three-dimensional camera and FIG. 7B is a viewfrom a right-side lens of the three-dimensional camera, according to atleast one aspect of the present disclosure.

FIG. 8 is a schematic of the surgical visualization system of FIG. 6 ,in which a camera-to-critical structure distance d_(w) from thethree-dimensional camera to the critical structure can be determined,according to at least one aspect of the present disclosure.

FIG. 9 is a schematic of a surgical visualization system utilizing twocameras to determine the position of an embedded critical structure,according to at least one aspect of the present disclosure.

FIG. 10A is a schematic of a surgical visualization system utilizing acamera that is moved axially between a plurality of known positions todetermine a position of an embedded critical structure, according to atleast one aspect of the present disclosure.

FIG. 10B is a schematic of the surgical visualization system of FIG.10A, in which the camera is moved axially and rotationally between aplurality of known positions to determine a position of the embeddedcritical structure, according to at least one aspect of the presentdisclosure.

FIG. 11 is a schematic of a control system for a surgical visualizationsystem, according to at least one aspect of the present disclosure.

FIG. 12 is a schematic of a structured light source for a surgicalvisualization system, according to at least one aspect of the presentdisclosure.

FIG. 13A is a graph of absorption coefficient verse wavelength forvarious biological materials, according to at least one aspect of thepresent disclosure.

FIG. 13B is a schematic of the visualization of anatomical structuresvia a spectral surgical visualization system, according to at least oneaspect of the present disclosure.

FIGS. 13C-13E depict illustrative hyperspectral identifying signaturesto differentiate anatomy from obscurants, wherein FIG. 13C is agraphical representation of a ureter signature versus obscurants, FIG.13D is a graphical representation of an artery signature versusobscurants, and FIG. 13E is a graphical representation of a nervesignature versus obscurants, according to at least one aspect of thepresent disclosure.

FIG. 14 is a schematic of a near infrared (NIR) time-of-flightmeasurement system configured to sense distance to a critical anatomicalstructure, the time-of-flight measurement system including a transmitter(emitter) and a receiver (sensor) positioned on a common device,according to at least one aspect of the present disclosure.

FIG. 15 is a schematic of an emitted wave, a received wave, and a delaybetween the emitted wave and the received wave of the NIR time-of-flightmeasurement system of FIG. 17A, according to at least one aspect of thepresent disclosure.

FIG. 16 illustrates a NIR time-of-flight measurement system configuredto sense a distance to different structures, the time-of-flightmeasurement system including a transmitter (emitter) and a receiver(sensor) on separate devices, according to at least one aspect of thepresent disclosure.

FIG. 17 is a block diagram of a computer-implemented interactivesurgical system, according to at least one aspect of the presentdisclosure.

FIG. 18 is a surgical system being used to perform a surgical procedurein an operating room, according to at least one aspect of the presentdisclosure.

FIG. 19 illustrates a computer-implemented interactive surgical system,according to at least one aspect of the present disclosure.

FIG. 20 illustrates a diagram of a situationally aware surgical system,according to at least one aspect of the present disclosure.

FIG. 21 illustrates a timeline depicting situational awareness of a hub,according to at least one aspect of the present disclosure.

FIG. 22 is a logic flow diagram of a process depicting a control programor a logic configuration for correlating visualization data withinstrument data, in accordance with at least one aspect of the presentdisclosure.

FIG. 23 is a schematic diagram of a surgical instrument, in accordancewith at least one aspect of the present disclosure.

FIG. 24 is a graph depicting a composite data set and Force-to-Close(“FTC”) and Force-to-Fire (“FTF”) virtual gauges, in accordance with atleast one aspect of the present disclosure.

FIG. 25A illustrates a normal view of a screen of a visualization systemdisplaying a live feed of an end effector in a surgical field of asurgical procedure, in accordance with at least one aspect of thepresent disclosure.

FIG. 25B illustrates an augmented view of a screen of a visualizationsystem displaying a live feed of an end effector in a surgical field ofa surgical procedure, in accordance with at least one aspect of thepresent disclosure.

FIG. 26 is a logic flow diagram of a process depicting a control programor a logic configuration for synchronizing movement of a virtualrepresentation of an end-effector component with actual movement of theend-effector component, in accordance with at least one aspect of thepresent disclosure.

FIG. 27 illustrates a body wall and an anatomical structure in a cavitybeneath the body wall, with trocars penetrating through the body wallinto the cavity, and a screen displaying trocar distances from theanatomical structure, risks associated with presenting surgicalinstruments through the trocars, and the estimated operating timesassociated therewith, in accordance with at least one aspect of thepresent disclosure.

FIG. 28 illustrates a virtual three-dimensional (“3D”) construct of astomach exposed to structured light from a structured light projector,in accordance with at least aspect of the present disclosure.

FIG. 29 is a logic flow diagram of a process depicting a control programor a logic configuration for correlating visualization data withinstrument data, wherein boxes with broken lines denote alternativeimplementations of the process, in accordance with at least one aspectof the present disclosure.

FIG. 30 illustrates a virtual 3D construct of a stomach exposed tostructured light from a structured light projector, in accordance withat least aspect of the present disclosure.

FIG. 31 is a logic flow diagram of a process depicting a control programor a logic configuration for proposing resection paths for removing aportion of an anatomical organ, wherein boxes with broken lines denotealternative implementations of the process, in accordance with at leastone aspect of the present disclosure.

FIG. 32A illustrates a live view of a surgical field on a screen of avisualization system at the onset of a surgical procedure, in accordancewith at least one aspect of the present disclosure.

FIG. 32B is an expanded view of a portion of the surgical field of FIG.32A outlining a proposed surgical resection path overlaid onto thesurgical field, in accordance with at least one aspect of the presentdisclosure.

FIG. 32C illustrates the live view of the surgical field of FIG. 32B atforty-three minutes beyond the onset of the surgical procedure, inaccordance with at least one aspect of the present disclosure.

FIG. 32D illustrates an expanded view of the surgical field of FIG. 32Coutlining a modification the proposed surgical resection path, inaccordance with at least one aspect of the present disclosure.

FIG. 33 is a logic flow diagram of a process depicting a control programor a logic configuration for presenting parameters of a surgicalinstrument onto, or near, a proposed surgical resection path, whereinboxes with broken lines denote alternative implementations of theprocess, in accordance with at least one aspect of the presentdisclosure.

FIG. 34 illustrates a virtual 3D construct of a stomach of a patientundergoing a sleeve gastrectomy, in accordance with at least one aspectof the present disclosure.

FIG. 35 illustrates a completed virtual resection of the stomach of FIG.34 .

FIGS. 36A-36C illustrate firing of a surgical stapling instrument, inaccordance with at least one aspect of the present disclosure.

FIG. 37 is a logic flow diagram of a process depicting a control programor a logic configuration for adjusting firing speed of a surgicalinstrument, in accordance with at least one aspect of the presentdisclosure.

FIG. 38 is a logic flow diagram of a process depicting a control programor a logic configuration for a proposed staple cartridge arrangementalong a proposed surgical resection path, in accordance with at leastone aspect of the present disclosure.

FIG. 39 is a logic flow diagram of a process depicting a control programor a logic configuration for proposing a surgical resection of an organportion, in accordance with at least one aspect of the presentdisclosure.

FIG. 40 is a logic flow diagram of a process depicting a control programor a logic configuration for estimating a capacity reduction of an organresulting from the removal of a selected portion of the organ, inaccordance with at least one aspect of the present disclosure.

FIG. 41A illustrates a patient's lungs exposed to structured light,which includes a portion to be resected during a surgical procedure, inaccordance with at least one aspect of the present disclosure.

FIG. 41B illustrates the patient's lungs of FIG. 41A after resection ofthe portion, in accordance with at least one aspect of the presentdisclosure.

FIG. 41C illustrates a graph measuring peak lung volume of the patient'slungs from FIGS. 41A and 41B prior to and after the resection of theportion of the lung, in accordance with at least one aspect of thepresent disclosure.

FIG. 42 illustrates a graph measuring partial pressure of carbon dioxide(“PCO₂”) in a patient's lungs prior to, immediately after, and a minuteafter, resection of a portion of the lung, in accordance with at leastone aspect of the present disclosure.

FIG. 43 is a logic flow diagram of a process depicting a control programor a logic configuration for detecting a tissue abnormality usingvisualization data and non-visualization data, in accordance with atleast one aspect of the present disclosure.

FIG. 44A illustrates a right lung in a first state with an imagingdevice emitting a pattern of light onto the surface thereof, inaccordance with at least one aspect of the present disclosure.

FIG. 44B illustrates the right lung of FIG. 44A in a second state withthe imaging device emitting a pattern of light onto the surface thereof,in accordance with at least one aspect of the present disclosure.

FIG. 44C illustrates a top portion of the right lung of FIG. 44A, inaccordance with at least one aspect of the present disclosure.

FIG. 44D illustrates a top portion of the right lung of FIG. 44B, inaccordance with at least one aspect of the present disclosure.

DESCRIPTION

Applicant of the present application owns the following U.S. PatentApplications, filed Dec. 30, 2019, each of which is herein incorporatedby reference in its entirety:

-   U.S. patent application Ser. No. 16/729,807, titled METHOD OF USING    IMAGING DEVICES IN SURGERY;-   U.S. patent application Ser. No. 16/729,803, titled ADAPTIVE    VISUALIZATION BY A SURGICAL SYSTEM;-   U.S. patent application Ser. No. 16/729,790, titled SURGICAL SYSTEM    CONTROL BASED ON MULTIPLE SENSED PARAMETERS;-   U.S. patent application Ser. No. 16/729,796, titled ADAPTIVE    SURGICAL SYSTEM CONTROL ACCORDING TO SURGICAL SMOKE PARTICLE    CHARACTERISTICS;-   U.S. patent application Ser. No. 16/729,737, titled ADAPTIVE    SURGICAL SYSTEM CONTROL ACCORDING TO SURGICAL SMOKE CLOUD    CHARACTERISTICS;-   U.S. patent application Ser. No. 16/729,740, titled SURGICAL SYSTEMS    CORRELATING VISUALIZATION DATA AND POWERED SURGICAL INSTRUMENT DATA;-   U.S. patent application Ser. No. 16/729,735, titled SURGICAL SYSTEM    FOR OVERLAYING SURGICAL INSTRUMENT DATA ONTO A VIRTUAL THREE    DIMENSIONAL CONSTRUCT OF AN ORGAN;-   U.S. patent application Ser. No. 16/729,729, titled SURGICAL SYSTEMS    FOR PROPOSING AND CORROBORATING ORGAN PORTION REMOVALS;-   U.S. patent application Ser. No. 16/729,778, titled SYSTEM AND    METHOD FOR DETERMINING, ADJUSTING, AND MANAGING RESECTION MARGIN    ABOUT A SUBJECT TISSUE;-   U.S. patent application Ser. No. 16/729,744, titled VISUALIZATION    SYSTEMS USING STRUCTURED LIGHT;-   U.S. patent application Ser. No. 16/729,747, titled DYNAMIC SURGICAL    VISUALIZATION SYSTEMS; and-   U.S. patent application Ser. No. 16/729,772, titled ANALYZING    SURGICAL TRENDS BY A SURGICAL SYSTEM.

Applicant of the present application owns the following U.S. PatentApplications, filed on Mar. 15, 2019, each of which is hereinincorporated by reference in its entirety:

-   U.S. patent application Ser. No. 16/354,417, titled INPUT CONTROLS    FOR ROBOTIC SURGERY, now U.S. Patent Application Publication No.    2020/0289219;-   U.S. patent application Ser. No. 16/354,420, titled DUAL MODE    CONTROLS FOR ROBOTIC SURGERY, now U.S. Patent Application    Publication No. 2020/0289228;-   U.S. patent application Ser. No. 16/354,422, titled MOTION CAPTURE    CONTROLS FOR ROBOTIC SURGERY, now U.S. Patent Application    Publication No. 2020/0289216;-   U.S. patent application Ser. No. 16/354,440, titled ROBOTIC SURGICAL    SYSTEMS WITH MECHANISMS FOR SCALING SURGICAL TOOL MOTION ACCORDING    TO TISSUE PROXIMITY, now U.S. Patent Application Publication No.    2020/0289220;-   U.S. patent application Ser. No. 16/354,444, titled ROBOTIC SURGICAL    SYSTEMS WITH MECHANISMS FOR SCALING CAMERA MAGNIFICATION ACCORDING    TO PROXIMITY OF SURGICAL TOOL TO TISSUE, now U.S. Patent Application    Publication No. 2020/0289205;-   U.S. patent application Ser. No. 16/354,454, titled ROBOTIC SURGICAL    SYSTEMS WITH SELECTIVELY LOCKABLE END EFFECTORS, now U.S. Patent    Application Publication No. 2020/0289221;-   U.S. patent application Ser. No. 16/354,461, titled SELECTABLE    VARIABLE RESPONSE OF SHAFT MOTION OF SURGICAL ROBOTIC SYSTEMS, now    U.S. Patent Application Publication No. 2020/0289222;-   U.S. patent application Ser. No. 16/354,470, titled SEGMENTED    CONTROL INPUTS FOR SURGICAL ROBOTIC SYSTEMS, now U.S. Patent    Application Publication No. 2020/0289223;-   U.S. patent application Ser. No. 16/354,474, titled ROBOTIC SURGICAL    CONTROLS HAVING FEEDBACK CAPABILITIES, now U.S. Patent Application    Publication No. 2020/0289229;-   U.S. patent application Ser. No. 16/354,478, titled ROBOTIC SURGICAL    CONTROLS WITH FORCE FEEDBACK, now U.S. Patent Application    Publication No. 2020/0289230; and-   U.S. patent application Ser. No. 16/354,481, titled JAW COORDINATION    OF ROBOTIC SURGICAL CONTROLS, now U.S. Patent Application    Publication No. 2020/0289217.

Applicant of the present application also owns the following U.S. PatentApplications, filed on Sep. 11, 2018, each of which is hereinincorporated by reference in its entirety:

-   U.S. patent application Ser. No. 16/128,179, titled SURGICAL    VISUALIZATION PLATFORM, now U.S. Patent Application Publication No.    2020/0015923;-   U.S. patent application Ser. No. 16/128,180, titled CONTROLLING AN    EMITTER ASSEMBLY PULSE SEQUENCE, now U.S. Patent Application    Publication No. 2020/0015900;-   U.S. patent application Ser. No. 16/128,198, titled SINGULAR EMR    SOURCE EMITTER ASSEMBLY, now U.S. Patent Application Publication No.    2020/0015668;-   U.S. patent application Ser. No. 16/128,207, titled COMBINATION    EMITTER AND CAMERA ASSEMBLY, now U.S. Patent Application Publication    No. 2020/0015925;-   U.S. patent application Ser. No. 16/128,176, titled SURGICAL    VISUALIZATION WITH PROXIMITY TRACKING FEATURES, now U.S. Patent    Application Publication No. 2020/0015899;-   U.S. patent application Ser. No. 16/128,187, titled SURGICAL    VISUALIZATION OF MULTIPLE TARGETS, now U.S. Patent Application    Publication No. 2020/0015903;-   U.S. patent application Ser. No. 16/128,192, titled VISUALIZATION OF    SURGICAL DEVICES, now U.S. Pat. No. 10,792,034;-   U.S. patent application Ser. No. 16/128,163, titled OPERATIVE    COMMUNICATION OF LIGHT, now U.S. Patent Application Publication No.    2020/0015897;-   U.S. patent application Ser. No. 16/128,197, titled ROBOTIC LIGHT    PROJECTION TOOLS, now U.S. Patent Application Publication No.    2020/0015924;-   U.S. patent application Ser. No. 16/128,164, titled SURGICAL    VISUALIZATION FEEDBACK SYSTEM, now U.S. Patent Application    Publication No. 2020/0015898;-   U.S. patent application Ser. No. 16/128,193, titled SURGICAL    VISUALIZATION AND MONITORING, now U.S. Patent Application    Publication No. 2020/0015906;-   U.S. patent application Ser. No. 16/128,195, titled INTEGRATION OF    IMAGING DATA, now U.S. Patent Application Publication No.    2020/0015907;-   U.S. patent application Ser. No. 16/128,170, titled    ROBOTICALLY-ASSISTED SURGICAL SUTURING SYSTEMS, now U.S. Pat. No.    10,925,598;-   U.S. patent application Ser. No. 16/128,183, titled SAFETY LOGIC FOR    SURGICAL SUTURING SYSTEMS, now U.S. Patent Application Publication    No. 2020/0015901;-   U.S. patent application Ser. No. 16/128,172, titled ROBOTIC SYSTEM    WITH SEPARATE PHOTOACOUSTIC RECEIVER, now U.S. Patent Application    Publication No. 2020/0015914; and-   U.S. patent application Ser. No. 16/128,185, titled FORCE SENSOR    THROUGH STRUCTURED LIGHT DEFLECTION, now U.S. Patent Application    Publication No. 2020/0015902.

Applicant of the present application also owns the following U.S. PatentApplications, filed on Mar. 29, 2018, each of which is hereinincorporated by reference in its entirety:

-   U.S. patent application Ser. No. 15/940,627, titled DRIVE    ARRANGEMENTS FOR ROBOT-ASSISTED SURGICAL PLATFORMS, now U.S. Patent    Application Publication No. 2019/0201111;-   U.S. patent application Ser. No. 15/940,676, titled AUTOMATIC TOOL    ADJUSTMENTS FOR ROBOT-ASSISTED SURGICAL PLATFORMS, now U.S. Patent    Application Publication No. 2019/0201142;-   U.S. patent application Ser. No. 15/940,711, titled SENSING    ARRANGEMENTS FOR ROBOT-ASSISTED SURGICAL PLATFORMS, now U.S. Patent    Application Publication No. 2019/0201120; and-   U.S. patent application Ser. No. 15/940,722, titled CHARACTERIZATION    OF TISSUE IRREGULARITIES THROUGH THE USE OF MONO-CHROMATIC LIGHT    REFRACTIVITY, now U.S. Patent Application Publication No.    2019/0200905.

Applicant of the present application owns the following U.S. PatentApplications, filed on Dec. 4, 2018, the disclosure of each of which isherein incorporated by reference in its entirety:

-   U.S. patent application Ser. No. 16/209,395, titled METHOD OF HUB    COMMUNICATION, now U.S. Patent Application Publication No.    2019/0201136;-   U.S. patent application Ser. No. 16/209,403, titled METHOD OF CLOUD    BASED DATA ANALYTICS FOR USE WITH THE HUB, now U.S. Patent    Application Publication No. 2019/0206569;-   U.S. patent application Ser. No. 16/209,407, titled METHOD OF    ROBOTIC HUB COMMUNICATION, DETECTION, AND CONTROL, now U.S. Patent    Application Publication No. 2019/0201137;-   U.S. patent application Ser. No. 16/209,416, titled METHOD OF HUB    COMMUNICATION, PROCESSING, DISPLAY, AND CLOUD ANALYTICS, now U.S.    Patent Application Publication No. 2019/0206562;-   U.S. patent application Ser. No. 16/209,423, titled METHOD OF    COMPRESSING TISSUE WITHIN A STAPLING DEVICE AND SIMULTANEOUSLY    DISPLAYING THE LOCATION OF THE TISSUE WITHIN THE JAWS, now U.S.    Patent Application Publication No. 2019/0200981;-   U.S. patent application Ser. No. 16/209,427, titled METHOD OF USING    REINFORCED FLEXIBLE CIRCUITS WITH MULTIPLE SENSORS TO OPTIMIZE    PERFORMANCE OF RADIO FREQUENCY DEVICES, now U.S. Patent Application    Publication No. 2019/0208641;-   U.S. patent application Ser. No. 16/209,433, titled METHOD OF    SENSING PARTICULATE FROM SMOKE EVACUATED FROM A PATIENT, ADJUSTING    THE PUMP SPEED BASED ON THE SENSED INFORMATION, AND COMMUNICATING    THE FUNCTIONAL PARAMETERS OF THE SYSTEM TO THE HUB, now U.S. Patent    Application Publication No. 2019/0201594;-   U.S. patent application Ser. No. 16/209,447, titled METHOD FOR SMOKE    EVACUATION FOR SURGICAL HUB, now U.S. Patent Application Publication    No. 2019/0201045;-   U.S. patent application Ser. No. 16/209,453, titled METHOD FOR    CONTROLLING SMART ENERGY DEVICES, now U.S. Patent Application    Publication No. 2019/0201046;-   U.S. patent application Ser. No. 16/209,458, titled METHOD FOR SMART    ENERGY DEVICE INFRASTRUCTURE, now U.S. Patent Application    Publication No. 2019/0201047;-   U.S. patent application Ser. No. 16/209,465, titled METHOD FOR    ADAPTIVE CONTROL SCHEMES FOR SURGICAL NETWORK CONTROL AND    INTERACTION, now U.S.

Patent Application Publication No. 2019/0206563;

-   U.S. patent application Ser. No. 16/209,478, titled METHOD FOR    SITUATIONAL AWARENESS FOR SURGICAL NETWORK OR SURGICAL NETWORK    CONNECTED DEVICE CAPABLE OF ADJUSTING FUNCTION BASED ON A SENSED    SITUATION OR USAGE, now U.S. Patent Application Publication No.    2019/0104919;-   U.S. patent application Ser. No. 16/209,490, titled METHOD FOR    FACILITY DATA COLLECTION AND INTERPRETATION, now U.S. Patent    Application Publication No. 2019/0206564; and-   U.S. patent application Ser. No. 16/209,491, titled METHOD FOR    CIRCULAR STAPLER CONTROL ALGORITHM ADJUSTMENT BASED ON SITUATIONAL    AWARENESS, now U.S. Patent Application Publication No. 2019/0200998.

Before explaining various aspects of a surgical visualization platformin detail, it should be noted that the illustrative examples are notlimited in application or use to the details of construction andarrangement of parts illustrated in the accompanying drawings anddescription. The illustrative examples may be implemented orincorporated in other aspects, variations, and modifications, and may bepracticed or carried out in various ways. Further, unless otherwiseindicated, the terms and expressions employed herein have been chosenfor the purpose of describing the illustrative examples for theconvenience of the reader and are not for the purpose of limitationthereof. Also, it will be appreciated that one or more of thefollowing-described aspects, expressions of aspects, and/or examples,can be combined with any one or more of the other following-describedaspects, expressions of aspects, and/or examples.

Surgical Visualization System

The present disclosure is directed to a surgical visualization platformthat leverages “digital surgery” to obtain additional information abouta patient's anatomy and/or a surgical procedure. The surgicalvisualization platform is further configured to convey data and/orinformation to one or more clinicians in a helpful manner. For example,various aspects of the present disclosure provide improved visualizationof the patient's anatomy and/or the surgical procedure.

“Digital surgery” can embrace robotic systems, advanced imaging,advanced instrumentation, artificial intelligence, machine learning,data analytics for performance tracking and benchmarking, connectivityboth inside and outside of the operating room (OR), and more. Althoughvarious surgical visualization platforms described herein can be used incombination with a robotic surgical system, surgical visualizationplatforms are not limited to use with a robotic surgical system. Incertain instances, advanced surgical visualization can occur withoutrobotics and/or with limited and/or optional robotic assistance.Similarly, digital surgery can occur without robotics and/or withlimited and/or optional robotic assistance.

In certain instances, a surgical system that incorporates a surgicalvisualization platform may enable smart dissection in order to identifyand avoid critical structures. Critical structures include anatomicalstructures such as a ureter, an artery such as a superior mesentericartery, a vein such as a portal vein, a nerve such as a phrenic nerve,and/or a tumor, among other anatomical structures. In other instances, acritical structure can be a foreign structure in the anatomical field,such as a surgical device, surgical fastener, clip, tack, bougie, band,and/or plate, for example. Critical structures can be determined on apatient-by-patient and/or a procedure-by-procedure basis. Examplecritical structures are further described herein. Smart dissectiontechnology may provide improved intraoperative guidance for dissectionand/or can enable smarter decisions with critical anatomy detection andavoidance technology, for example.

A surgical system incorporating a surgical visualization platform mayalso enable smart anastomosis technologies that provide more consistentanastomoses at optimal location(s) with improved workflow. Cancerlocalization technologies may also be improved with the various surgicalvisualization platforms and procedures described herein. For example,cancer localization technologies can identify and track a cancerlocation, orientation, and its margins. In certain instances, the cancerlocalizations technologies may compensate for movement of a tool, apatient, and/or the patient's anatomy during a surgical procedure inorder to provide guidance back to the point of interest for theclinician.

In certain aspects of the present disclosure, a surgical visualizationplatform may provide improved tissue characterization and/or lymph nodediagnostics and mapping. For example, tissue characterizationtechnologies may characterize tissue type and health without the needfor physical haptics, especially when dissecting and/or placing staplingdevices within the tissue. Certain tissue characterization technologiesdescribed herein may be utilized without ionizing radiation and/orcontrast agents. With respect to lymph node diagnostics and mapping, asurgical visualization platform may preoperatively locate, map, andideally diagnose the lymph system and/or lymph nodes involved incancerous diagnosis and staging, for example.

During a surgical procedure, the information available to the clinicianvia the “naked eye” and/or an imaging system may provide an incompleteview of the surgical site. For example, certain structures, such asstructures embedded or buried within an organ, can be at least partiallyconcealed or hidden from view. Additionally, certain dimensions and/orrelative distances can be difficult to ascertain with existing sensorsystems and/or difficult for the “naked eye” to perceive. Moreover,certain structures can move preoperatively (e.g. before a surgicalprocedure but after a preoperative scan) and/or intraoperatively. Insuch instances, the clinician can be unable to accurately determine thelocation of a critical structure intraoperatively.

When the position of a critical structure is uncertain and/or when theproximity between the critical structure and a surgical tool is unknown,a clinician's decision-making process can be inhibited. For example, aclinician may avoid certain areas in order to avoid inadvertentdissection of a critical structure; however, the avoided area may beunnecessarily large and/or at least partially misplaced. Due touncertainty and/or overly/excessive exercises in caution, the clinicianmay not access certain desired regions. For example, excess caution maycause a clinician to leave a portion of a tumor and/or other undesirabletissue in an effort to avoid a critical structure even if the criticalstructure is not in the particular area and/or would not be negativelyimpacted by the clinician working in that particular area. In certaininstances, surgical results can be improved with increased knowledgeand/or certainty, which can allow a surgeon to be more accurate and, incertain instances, less conservative/more aggressive with respect toparticular anatomical areas.

In various aspects, the present disclosure provides a surgicalvisualization system for intraoperative identification and avoidance ofcritical structures. In one aspect, the present disclosure provides asurgical visualization system that enables enhanced intraoperativedecision making and improved surgical outcomes. In various aspects, thedisclosed surgical visualization system provides advanced visualizationcapabilities beyond what a clinician sees with the “naked eye” and/orbeyond what an imaging system can recognize and/or convey to theclinician. The various surgical visualization systems can augment andenhance what a clinician is able to know prior to tissue treatment (e.g.dissection) and, thus, may improve outcomes in various instances.

For example, a visualization system can include a first light emitterconfigured to emit a plurality of spectral waves, a second light emitterconfigured to emit a light pattern, and one or more receivers, orsensors, configured to detect visible light, molecular responses to thespectral waves (spectral imaging), and/or the light pattern. It shouldbe noted that throughout the following disclosure, any reference to“light,” unless specifically in reference to visible light, can includeelectromagnetic radiation (EMR) or photons in the visible and/ornon-visible portions of the EMR wavelength spectrum. The surgicalvisualization system can also include an imaging system and a controlcircuit in signal communication with the receiver(s) and the imagingsystem. Based on output from the receiver(s), the control circuit candetermine a geometric surface map, i.e. three-dimensional surfacetopography, of the visible surfaces at the surgical site and one or moredistances with respect to the surgical site. In certain instances, thecontrol circuit can determine one more distances to an at leastpartially concealed structure. Moreover, the imaging system can conveythe geometric surface map and the one or more distances to a clinician.In such instances, an augmented view of the surgical site provided tothe clinician can provide a representation of the concealed structurewithin the relevant context of the surgical site. For example, theimaging system can virtually augment the concealed structure on thegeometric surface map of the concealing and/or obstructing tissuesimilar to a line drawn on the ground to indicate a utility line belowthe surface. Additionally or alternatively, the imaging system canconvey the proximity of one or more surgical tools to the visible andobstructing tissue and/or to the at least partially concealed structureand/or the depth of the concealed structure below the visible surface ofthe obstructing tissue. For example, the visualization system candetermine a distance with respect to the augmented line on the surfaceof the visible tissue and convey the distance to the imaging system.

In various aspects of the present disclosure, a surgical visualizationsystem is disclosed for intraoperative identification and avoidance ofcritical structures. Such a surgical visualization system can providevaluable information to a clinician during a surgical procedure. As aresult, the clinician can confidently maintain momentum throughout thesurgical procedure knowing that the surgical visualization system istracking a critical structure such as a ureter, specific nerves, and/orcritical blood vessels, for example, which may be approached duringdissection, for example. In one aspect, the surgical visualizationsystem can provide an indication to the clinician in sufficient time forthe clinician to pause and/or slow down the surgical procedure andevaluate the proximity to the critical structure to prevent inadvertentdamage thereto. The surgical visualization system can provide an ideal,optimized, and/or customizable amount of information to the clinician toallow the clinician to move confidently and/or quickly through tissuewhile avoiding inadvertent damage to healthy tissue and/or criticalstructure(s) and, thus, to minimize the risk of harm resulting from thesurgical procedure.

FIG. 1 is a schematic of a surgical visualization system 100 accordingto at least one aspect of the present disclosure. The surgicalvisualization system 100 can create a visual representation of acritical structure 101 within an anatomical field. The surgicalvisualization system 100 can be used for clinical analysis and/ormedical intervention, for example. In certain instances, the surgicalvisualization system 100 can be used intraoperatively to providereal-time, or near real-time, information to the clinician regardingproximity data, dimensions, and/or distances during a surgicalprocedure. The surgical visualization system 100 is configured forintraoperative identification of critical structure(s) and/or tofacilitate the avoidance of the critical structure(s) 101 by a surgicaldevice. For example, by identifying the critical structure 101, aclinician can avoid maneuvering a surgical device around the criticalstructure 101 and/or a region in a predefined proximity of the criticalstructure 101 during a surgical procedure. The clinician can avoiddissection of and/or near a vein, artery, nerve, and/or vessel, forexample, identified as the critical structure 101, for example. Invarious instances, the critical structure 101 can be determined on apatient-by-patient and/or a procedure-by-procedure basis.

The surgical visualization system 100 incorporates tissue identificationand geometric surface mapping in combination with a distance sensorsystem 104. In combination, these features of the surgical visualizationsystem 100 can determine a position of a critical structure 101 withinthe anatomical field and/or the proximity of a surgical device 102 tothe surface 105 of the visible tissue and/or to the critical structure101. Moreover, the surgical visualization system 100 includes an imagingsystem that includes an imaging device 120, such as a camera, forexample, configured to provide real-time views of the surgical site. Invarious instances, the imaging device 120 is a spectral camera (e.g. ahyperspectral camera, multispectral camera, or selective spectralcamera), which is configured to detect reflected spectral waveforms andgenerate a spectral cube of images based on the molecular response tothe different wavelengths. Views from the imaging device 120 can beprovided to a clinician and, in various aspects of the presentdisclosure, can be augmented with additional information based on thetissue identification, landscape mapping, and the distance sensor system104. In such instances, the surgical visualization system 100 includes aplurality of subsystems—an imaging subsystem, a surface mappingsubsystem, a tissue identification subsystem, and/or a distancedetermining subsystem. These subsystems can cooperate tointra-operatively provide advanced data synthesis and integratedinformation to the clinician(s).

The imaging device can include a camera or imaging sensor that isconfigured to detect visible light, spectral light waves (visible orinvisible), and a structured light pattern (visible or invisible), forexample. In various aspects of the present disclosure, the imagingsystem can include an imaging device such as an endoscope, for example.Additionally or alternatively, the imaging system can include an imagingdevice such as an arthroscope, angioscope, bronchoscope,choledochoscope, colonoscope, cytoscope, duodenoscope, enteroscope,esophagogastro-duodenoscope (gastroscope), laryngoscope,nasopharyngo-neproscope, sigmoidoscope, thoracoscope, ureteroscope, orexoscope, for example. In other instances, such as in open surgeryapplications, the imaging system may not include a scope.

In various aspects of the present disclosure, the tissue identificationsubsystem can be achieved with a spectral imaging system. The spectralimaging system can rely on hyperspectral imaging, multispectral imaging,or selective spectral imaging, for example. Hyperspectral imaging oftissue is further described in U.S. Pat. No. 9,274,047, titled SYSTEMAND METHOD FOR GROSS ANATOMIC PATHOLOGY USING HYPERSPECTRAL IMAGING,issued Mar. 1, 2016, which is incorporated by reference herein in itsentirety.

In various aspect of the present disclosure, the surface mappingsubsystem can be achieved with a light pattern system, as furtherdescribed herein. The use of a light pattern (or structured light) forsurface mapping is known. Known surface mapping techniques can beutilized in the surgical visualization systems described herein.

Structured light is the process of projecting a known pattern (often agrid or horizontal bars) on to a surface. U.S. Patent ApplicationPublication No. 2017/0055819, titled SET COMPRISING A SURGICALINSTRUMENT, published Mar. 2, 2017, and U.S. Patent ApplicationPublication No. 2017/0251900, titled DEPICTION SYSTEM, published Sep. 7,2017, disclose a surgical system comprising a light source and aprojector for projecting a light pattern. U.S. Patent ApplicationPublication No. 2017/0055819, titled SET COMPRISING A SURGICALINSTRUMENT, published Mar. 2, 2017, and U.S. Patent ApplicationPublication No. 2017/0251900, titled DEPICTION SYSTEM, published Sep. 7,2017, are incorporated by reference herein in their respectiveentireties.

In various aspects of the present disclosure, the distance determiningsystem can be incorporated into the surface mapping system. For example,structured light can be utilized to generate a three-dimensional virtualmodel of the visible surface and determine various distances withrespect to the visible surface. Additionally or alternatively, thedistance determining system can rely on time-of-flight measurements todetermine one or more distances to the identified tissue (or otherstructures) at the surgical site.

FIG. 2 is a schematic diagram of a control system 133, which can beutilized with the surgical visualization system 100. The control system133 includes a control circuit 132 in signal communication with a memory134. The memory 134 stores instructions executable by the controlcircuit 132 to determine and/or recognize critical structures (e.g. thecritical structure 101 in FIG. 1 ), determine and/or compute one or moredistances and/or three-dimensional digital representations, and tocommunicate certain information to one or more clinicians. For example,the memory 134 stores surface mapping logic 136, imaging logic 138,tissue identification logic 140, or distance determining logic 141 orany combinations of the logic 136, 138, 140, and 141. The control system133 also includes an imaging system 142 having one or more cameras 144(like the imaging device 120 in FIG. 1 ), one or more displays 146, orone or more controls 148 or any combinations of these elements. Thecamera 144 can include one or more image sensors 135 to receive signalsfrom various light sources emitting light at various visible andinvisible spectra (e.g. visible light, spectral imagers,three-dimensional lens, among others). The display 146 can include oneor more screens or monitors for depicting real, virtual, and/orvirtually-augmented images and/or information to one or more clinicians.

In various aspects, the heart of the camera 144 is the image sensor 135.Generally, modern image sensors 135 are solid-state electronic devicescontaining up to millions of discrete photodetector sites called pixels.The image sensor 135 technology falls into one of two categories:Charge-Coupled Device (CCD) and Complementary Metal Oxide Semiconductor(CMOS) imagers and more recently, short-wave infrared (SWIR) is anemerging technology in imaging. Another type of image sensor 135 employsa hybrid CCD/CMOS architecture (sold under the name “sCMOS”) andconsists of CMOS readout integrated circuits (ROICs) that are bumpbonded to a CCD imaging substrate. CCD and CMOS image sensors 135 aresensitive to wavelengths from approximately 350-1050 nm, although therange is usually given from 400-1000 nm. CMOS sensors are, in general,more sensitive to IR wavelengths than CCD sensors. Solid state imagesensors 135 are based on the photoelectric effect and, as a result,cannot distinguish between colors. Accordingly, there are two types ofcolor CCD cameras: single chip and three-chip. Single chip color CCDcameras offer a common, low-cost imaging solution and use a mosaic (e.g.Bayer) optical filter to separate incoming light into a series of colorsand employ an interpolation algorithm to resolve full color images. Eachcolor is, then, directed to a different set of pixels. Three-chip colorCCD cameras provide higher resolution by employing a prism to directeach section of the incident spectrum to a different chip. More accuratecolor reproduction is possible, as each point in space of the object hasseparate RGB intensity values, rather than using an algorithm todetermine the color. Three-chip cameras offer extremely highresolutions.

The control system 133 also includes a spectral light source 150 and astructured light source 152. In certain instances, a single source canbe pulsed to emit wavelengths of light in the spectral light source 150range and wavelengths of light in the structured light source 152 range.Alternatively, a single light source can be pulsed to provide light inthe invisible spectrum (e.g. infrared spectral light) and wavelengths oflight on the visible spectrum. The spectral light source 150 can be ahyperspectral light source, a multispectral light source, and/or aselective spectral light source, for example. In various instances, thetissue identification logic 140 can identify critical structure(s) viadata from the spectral light source 150 received by the image sensor 135portion of the camera 144. The surface mapping logic 136 can determinethe surface contours of the visible tissue based on reflected structuredlight. With time-of-flight measurements, the distance determining logic141 can determine one or more distance(s) to the visible tissue and/orthe critical structure 101. One or more outputs from the surface mappinglogic 136, the tissue identification logic 140, and the distancedetermining logic 141, can be provided to the imaging logic 138, andcombined, blended, and/or overlaid to be conveyed to a clinician via thedisplay 146 of the imaging system 142.

The description now turns briefly to FIGS. 2A-2C to describe variousaspects of the control circuit 132 for controlling various aspects ofthe surgical visualization system 100. Turning to FIG. 2A, there isillustrated a control circuit 400 configured to control aspects of thesurgical visualization system 100, according to at least one aspect ofthis disclosure. The control circuit 400 can be configured to implementvarious processes described herein. The control circuit 400 may comprisea microcontroller comprising one or more processors 402 (e.g.,microprocessor, microcontroller) coupled to at least one memory circuit404. The memory circuit 404 stores machine-executable instructions that,when executed by the processor 402, cause the processor 402 to executemachine instructions to implement various processes described herein.The processor 402 may be any one of a number of single-core or multicoreprocessors known in the art. The memory circuit 404 may comprisevolatile and non-volatile storage media. The processor 402 may includean instruction processing unit 406 and an arithmetic unit 408. Theinstruction processing unit may be configured to receive instructionsfrom the memory circuit 404 of this disclosure.

FIG. 2B illustrates a combinational logic circuit 410 configured tocontrol aspects of the surgical visualization system 100, according toat least one aspect of this disclosure. The combinational logic circuit410 can be configured to implement various processes described herein.The combinational logic circuit 410 may comprise a finite state machinecomprising a combinational logic 412 configured to receive dataassociated with the surgical instrument or tool at an input 414, processthe data by the combinational logic 412, and provide an output 416.

FIG. 2C illustrates a sequential logic circuit 420 configured to controlaspects of the surgical visualization system 100, according to at leastone aspect of this disclosure. The sequential logic circuit 420 or thecombinational logic 422 can be configured to implement various processesdescribed herein. The sequential logic circuit 420 may comprise a finitestate machine. The sequential logic circuit 420 may comprise acombinational logic 422, at least one memory circuit 424, and a clock429, for example. The at least one memory circuit 424 can store acurrent state of the finite state machine. In certain instances, thesequential logic circuit 420 may be synchronous or asynchronous. Thecombinational logic 422 is configured to receive data associated with asurgical device or system from an input 426, process the data by thecombinational logic 422, and provide an output 428. In other aspects,the circuit may comprise a combination of a processor (e.g., processor402 in FIG. 2A) and a finite state machine to implement variousprocesses herein. In other aspects, the finite state machine maycomprise a combination of a combinational logic circuit (e.g.,combinational logic circuit 410, FIG. 2B) and the sequential logiccircuit 420.

Referring again to the surgical visualization system 100 in FIG. 1 , thecritical structure 101 can be an anatomical structure of interest. Forexample, the critical structure 101 can be a ureter, an artery such as asuperior mesenteric artery, a vein such as a portal vein, a nerve suchas a phrenic nerve, and/or a tumor, among other anatomical structures.In other instances, the critical structure 101 can be a foreignstructure in the anatomical field, such as a surgical device, surgicalfastener, clip, tack, bougie, band, and/or plate, for example. Examplecritical structures are further described herein and in theaforementioned U.S. Patent Applications, including U.S. patentapplication Ser. No. 16/128,192, titled VISUALIZATION OF SURGICALDEVICES, filed Sep. 11, 2018, now U.S. Pat. No. 10,792,034, for example,which are incorporated by reference herein in their respectiveentireties.

In one aspect, the critical structure 101 may be embedded in tissue 103.Stated differently, the critical structure 101 may be positioned belowthe surface 105 of the tissue 103. In such instances, the tissue 103conceals the critical structure 101 from the clinician's view. Thecritical structure 101 is also obscured from the view of the imagingdevice 120 by the tissue 103. The tissue 103 can be fat, connectivetissue, adhesions, and/or organs, for example. In other instances, thecritical structure 101 can be partially obscured from view.

FIG. 1 also depicts the surgical device 102. The surgical device 102includes an end effector having opposing jaws extending from the distalend of the shaft of the surgical device 102. The surgical device 102 canbe any suitable surgical device such as, for example, a dissector, astapler, a grasper, a clip applier, and/or an energy device includingmono-polar probes, bi-polar probes, ablation probes, and/or anultrasonic end effector. Additionally or alternatively, the surgicaldevice 102 can include another imaging or diagnostic modality, such asan ultrasound device, for example. In one aspect of the presentdisclosure, the surgical visualization system 100 can be configured toachieve identification of one or more critical structures 101 and theproximity of the surgical device 102 to the critical structure(s) 101.

The imaging device 120 of the surgical visualization system 100 isconfigured to detect light at various wavelengths, such as, for example,visible light, spectral light waves (visible or invisible), and astructured light pattern (visible or invisible). The imaging device 120may include a plurality of lenses, sensors, and/or receivers fordetecting the different signals. For example, the imaging device 120 canbe a hyperspectral, multispectral, or selective spectral camera, asfurther described herein. The imaging device 120 can also include awaveform sensor 122 (such as a spectral image sensor, detector, and/orthree-dimensional camera lens). For example, the imaging device 120 caninclude a right-side lens and a left-side lens used together to recordtwo two-dimensional images at the same time and, thus, generate athree-dimensional image of the surgical site, render a three-dimensionalimage of the surgical site, and/or determine one or more distances atthe surgical site. Additionally or alternatively, the imaging device 120can be configured to receive images indicative of the topography of thevisible tissue and the identification and position of hidden criticalstructures, as further described herein. For example, the field of viewof the imaging device 120 can overlap with a pattern of light(structured light) on the surface 105 of the tissue, as shown in FIG. 1.

In one aspect, the surgical visualization system 100 may be incorporatedinto a robotic system 110. For example, the robotic system 110 mayinclude a first robotic arm 112 and a second robotic arm 114. Therobotic arms 112, 114 include rigid structural members 116 and joints118, which can include servomotor controls. The first robotic arm 112 isconfigured to maneuver the surgical device 102, and the second roboticarm 114 is configured to maneuver the imaging device 120. A roboticcontrol unit can be configured to issue control motions to the roboticarms 112, 114, which can affect the surgical device 102 and the imagingdevice 120, for example.

The surgical visualization system 100 also includes an emitter 106,which is configured to emit a pattern of light, such as stripes, gridlines, and/or dots, to enable the determination of the topography orlandscape of the surface 105. For example, projected light arrays 130can be used for three-dimensional scanning and registration on thesurface 105. The projected light arrays 130 can be emitted from theemitter 106 located on the surgical device 102 and/or one of the roboticarms 112, 114 and/or the imaging device 120, for example. In one aspect,the projected light array 130 is employed to determine the shape definedby the surface 105 of the tissue 103 and/or the motion of the surface105 intraoperatively. The imaging device 120 is configured to detect theprojected light arrays 130 reflected from the surface 105 to determinethe topography of the surface 105 and various distances with respect tothe surface 105.

In one aspect, the imaging device 120 also may include an opticalwaveform emitter 123 that is configured to emit electromagneticradiation 124 (NIR photons) that can penetrate the surface 105 of thetissue 103 and reach the critical structure 101. The imaging device 120and the optical waveform emitter 123 thereon can be positionable by therobotic arm 114. A corresponding waveform sensor 122 (an image sensor,spectrometer, or vibrational sensor, for example) on the imaging device120 is configured to detect the effect of the electromagnetic radiationreceived by the waveform sensor 122. The wavelengths of theelectromagnetic radiation 124 emitted by the optical waveform emitter123 can be configured to enable the identification of the type ofanatomical and/or physical structure, such as the critical structure101. The identification of the critical structure 101 can beaccomplished through spectral analysis, photo-acoustics, and/orultrasound, for example. In one aspect, the wavelengths of theelectromagnetic radiation 124 may be variable. The waveform sensor 122and optical waveform emitter 123 may be inclusive of a multispectralimaging system and/or a selective spectral imaging system, for example.In other instances, the waveform sensor 122 and optical waveform emitter123 may be inclusive of a photoacoustic imaging system, for example. Inother instances, the optical waveform emitter 123 can be positioned on aseparate surgical device from the imaging device 120.

The surgical visualization system 100 also may include the distancesensor system 104 configured to determine one or more distances at thesurgical site. In one aspect, the time-of-flight distance sensor system104 may be a time-of-flight distance sensor system that includes anemitter, such as the emitter 106, and a receiver 108, which can bepositioned on the surgical device 102. In other instances, thetime-of-flight emitter can be separate from the structured lightemitter. In one general aspect, the emitter 106 portion of thetime-of-flight distance sensor system 104 may include a very tiny lasersource and the receiver 108 portion of the time-of-flight distancesensor system 104 may include a matching sensor. The time-of-flightdistance sensor system 104 can detect the “time of flight,” or how longthe laser light emitted by the emitter 106 has taken to bounce back tothe sensor portion of the receiver 108. Use of a very narrow lightsource in the emitter 106 enables the distance sensor system 104 todetermining the distance to the surface 105 of the tissue 103 directlyin front of the distance sensor system 104. Referring still to FIG. 1 ,d_(e) is the emitter-to-tissue distance from the emitter 106 to thesurface 105 of the tissue 103 and d_(t) is the device-to-tissue distancefrom the distal end of the surgical device 102 to the surface 105 of thetissue. The distance sensor system 104 can be employed to determine theemitter-to-tissue distance d_(e). The device-to-tissue distance d_(t) isobtainable from the known position of the emitter 106 on the shaft ofthe surgical device 102 relative to the distal end of the surgicaldevice 102. In other words, when the distance between the emitter 106and the distal end of the surgical device 102 is known, thedevice-to-tissue distance d_(t) can be determined from theemitter-to-tissue distance d_(e). In certain instances, the shaft of thesurgical device 102 can include one or more articulation joints, and canbe articulatable with respect to the emitter 106 and the jaws. Thearticulation configuration can include a multi-joint vertebrae-likestructure, for example. In certain instances, a three-dimensional cameracan be utilized to triangulate one or more distances to the surface 105.

In various instances, the receiver 108 for the time-of-flight distancesensor system 104 can be mounted on a separate surgical device insteadof the surgical device 102. For example, the receiver 108 can be mountedon a cannula or trocar through which the surgical device 102 extends toreach the surgical site. In still other instances, the receiver 108 forthe time-of-flight distance sensor system 104 can be mounted on aseparate robotically-controlled arm (e.g. the robotic arm 114), on amovable arm that is operated by another robot, and/or to an operatingroom (OR) table or fixture. In certain instances, the imaging device 120includes the time-of-flight receiver 108 to determine the distance fromthe emitter 106 to the surface 105 of the tissue 103 using a linebetween the emitter 106 on the surgical device 102 and the imagingdevice 120. For example, the distance d_(e) can be triangulated based onknown positions of the emitter 106 (on the surgical device 102) and thereceiver 108 (on the imaging device 120) of the time-of-flight distancesensor system 104. The three-dimensional position of the receiver 108can be known and/or registered to the robot coordinate planeintraoperatively.

In certain instances, the position of the emitter 106 of thetime-of-flight distance sensor system 104 can be controlled by the firstrobotic arm 112 and the position of the receiver 108 of thetime-of-flight distance sensor system 104 can be controlled by thesecond robotic arm 114. In other instances, the surgical visualizationsystem 100 can be utilized apart from a robotic system. In suchinstances, the distance sensor system 104 can be independent of therobotic system.

In certain instances, one or more of the robotic arms 112, 114 may beseparate from a main robotic system used in the surgical procedure. Atleast one of the robotic arms 112, 114 can be positioned and registeredto a particular coordinate system without a servomotor control. Forexample, a closed-loop control system and/or a plurality of sensors forthe robotic arms 110 can control and/or register the position of therobotic arm(s) 112, 114 relative to the particular coordinate system.Similarly, the position of the surgical device 102 and the imagingdevice 120 can be registered relative to a particular coordinate system.

Referring still to FIG. 1 , d_(w) is the camera-to-critical structuredistance from the optical waveform emitter 123 located on the imagingdevice 120 to the surface of the critical structure 101, and d_(A) isthe depth of the critical structure 101 below the surface 105 of thetissue 103 (i.e., the distance between the portion of the surface 105closest to the surgical device 102 and the critical structure 101). Invarious aspects, the time-of-flight of the optical waveforms emittedfrom the optical waveform emitter 123 located on the imaging device 120can be configured to determine the camera-to-critical structure distanced_(w). The use of spectral imaging in combination with time-of-flightsensors is further described herein. Moreover, referring now to FIG. 3 ,in various aspects of the present disclosure, the depth d_(A) of thecritical structure 101 relative to the surface 105 of the tissue 103 canbe determined by triangulating from the distance d_(w) and knownpositions of the emitter 106 on the surgical device 102 and the opticalwaveform emitter 123 on the imaging device 120 (and, thus, the knowndistance d_(x) therebetween) to determine the distance d_(y), which isthe sum of the distances d_(e) and d_(A).

Additionally or alternatively, time-of-flight from the optical waveformemitter 123 can be configured to determine the distance from the opticalwaveform emitter 123 to the surface 105 of the tissue 103. For example,a first waveform (or range of waveforms) can be utilized to determinethe camera-to-critical structure distance d_(w) and a second waveform(or range of waveforms) can be utilized to determine the distance to thesurface 105 of the tissue 103. In such instances, the differentwaveforms can be utilized to determine the depth of the criticalstructure 101 below the surface 105 of the tissue 103.

Additionally or alternatively, in certain instances, the distance d_(A)can be determined from an ultrasound, a registered magnetic resonanceimaging (MRI) or computerized tomography (CT) scan. In still otherinstances, the distance d_(A) can be determined with spectral imagingbecause the detection signal received by the imaging device can varybased on the type of material. For example, fat can decrease thedetection signal in a first way, or a first amount, and collagen candecrease the detection signal in a different, second way, or a secondamount.

Referring now to a surgical visualization system 160 in FIG. 4 , inwhich a surgical device 162 includes the optical waveform emitter 123and the waveform sensor 122 that is configured to detect the reflectedwaveforms. The optical waveform emitter 123 can be configured to emitwaveforms for determining the distances d_(t) and d_(w) from a commondevice, such as the surgical device 162, as further described herein. Insuch instances, the distance d_(A) from the surface 105 of the tissue103 to the surface of the critical structure 101 can be determined asfollows:d _(A) =d _(w) −d _(t).

As disclosed herein, various information regarding visible tissue,embedded critical structures, and surgical devices can be determined byutilizing a combination approach that incorporates one or moretime-of-flight distance sensors, spectral imaging, and/or structuredlight arrays in combination with an image sensor configured to detectthe spectral wavelengths and the structured light arrays. Moreover, theimage sensor can be configured to receive visible light and, thus,provide images of the surgical site to an imaging system. Logic oralgorithms are employed to discern the information received from thetime-of-flight sensors, spectral wavelengths, structured light, andvisible light and render three-dimensional images of the surface tissueand underlying anatomical structures. In various instances, the imagingdevice 120 can include multiple image sensors.

The camera-to-critical structure distance d_(w) can also be detected inone or more alternative ways. In one aspect, a fluoroscopy visualizationtechnology, such as fluorescent indosciedine green (ICG), for example,can be utilized to illuminate a critical structure 201, as shown inFIGS. 6-8 . A camera 220 can include two optical waveforms sensors 222,224, which take simultaneous left-side and right-side images of thecritical structure 201 (FIGS. 7A and 7B). In such instances, the camera220 can depict a glow of the critical structure 201 below the surface205 of the tissue 203, and the distance d_(w) can be determined by theknown distance between the sensors 222 and 224. In certain instances,distances can be determined more accurately by utilizing more than onecamera or by moving a camera between multiple locations. In certainaspects, one camera can be controlled by a first robotic arm and asecond camera by another robotic arm. In such a robotic system, onecamera can be a follower camera on a follower arm, for example. Thefollower arm, and camera thereon, can be programmed to track the othercamera and to maintain a particular distance and/or lens angle, forexample.

In still other aspects, the surgical visualization system 100 may employtwo separate waveform receivers (i.e. cameras/image sensors) todetermine d_(w). Referring now to FIG. 9 , if a critical structure 301or the contents thereof (e.g. a vessel or the contents of the vessel)can emit a signal 302, such as with fluoroscopy, then the actuallocation can be triangulated from two separate cameras 320 a, 320 b atknown locations.

In another aspect, referring now to FIGS. 10A and 10B, a surgicalvisualization system may employ a dithering or moving camera 440 todetermine the distance d_(w). The camera 440 is robotically-controlledsuch that the three-dimensional coordinates of the camera 440 at thedifferent positions are known. In various instances, the camera 440 canpivot at a cannula or patient interface. For example, if a criticalstructure 401 or the contents thereof (e.g. a vessel or the contents ofthe vessel) can emit a signal, such as with fluoroscopy, for example,then the actual location can be triangulated from the camera 440 movedrapidly between two or more known locations. In FIG. 10A, the camera 440is moved axially along an axis A. More specifically, the camera 440translates a distance d₁ closer to the critical structure 401 along theaxis A to the location indicated as a location 440′, such as by movingin and out on a robotic arm. As the camera 440 moves the distance d₁ andthe size of view change with respect to the critical structure 401, thedistance to the critical structure 401 can be calculated. For example, a4.28 mm axial translation (the distance d₁) can correspond to an angleθ₁ of 6.28 degrees and an angle θ₂ of 8.19 degrees. Additionally oralternatively, the camera 440 can rotate or sweep along an arc betweendifferent positions. Referring now to FIG. 10B, the camera 440 is movedaxially along the axis A and is rotated an angle θ₃ about the axis A. Apivot point 442 for rotation of the camera 440 is positioned at thecannula/patient interface. In FIG. 10B, the camera 440 is translated androtated to a location 440″. As the camera 440 moves and the edge of viewchanges with respect to the critical structure 401, the distance to thecritical structure 401 can be calculated. In FIG. 10B, a distance d₂ canbe 9.01 mm, for example, and the angle θ₃ can be 0.9 degrees, forexample.

FIG. 5 depicts a surgical visualization system 500, which is similar tothe surgical visualization system 100 in many respects. In variousinstances, the surgical visualization system 500 can be a furtherexemplification of the surgical visualization system 100. Similar to thesurgical visualization system 100, the surgical visualization system 500includes a surgical device 502 and an imaging device 520. The imagingdevice 520 includes a spectral light emitter 523, which is configured toemit spectral light in a plurality of wavelengths to obtain a spectralimage of hidden structures, for example. The imaging device 520 can alsoinclude a three-dimensional camera and associated electronic processingcircuits in various instances. The surgical visualization system 500 isshown being utilized intraoperatively to identify and facilitateavoidance of certain critical structures, such as a ureter 501 a andvessels 501 b in an organ 503 (the uterus in this example), that are notvisible on the surface.

The surgical visualization system 500 is configured to determine anemitter-to-tissue distance d_(e) from an emitter 506 on the surgicaldevice 502 to a surface 505 of the uterus 503 via structured light. Thesurgical visualization system 500 is configured to extrapolate adevice-to-tissue distance d_(t) from the surgical device 502 to thesurface 505 of the uterus 503 based on the emitter-to-tissue distanced_(e). The surgical visualization system 500 is also configured todetermine a tissue-to-ureter distance d_(A) from the ureter 501 a to thesurface 505 and a camera-to ureter distance d_(w) from the imagingdevice 520 to the ureter 501 a. As described herein with respect to FIG.1 , for example, the surgical visualization system 500 can determine thedistance d_(w) with spectral imaging and time-of-flight sensors, forexample. In various instances, the surgical visualization system 500 candetermine (e.g. triangulate) the tissue-to-ureter distance d_(A) (ordepth) based on other distances and/or the surface mapping logicdescribed herein.

Referring now to FIG. 11 , where a schematic of a control system 600 fora surgical visualization system, such as the surgical visualizationsystem 100, for example, is depicted. The control system 600 is aconversion system that integrates spectral signature tissueidentification and structured light tissue positioning to identifycritical structures, especially when those structures are obscured byother tissue, such as fat, connective tissue, blood, and/or otherorgans, for example. Such technology could also be useful for detectingtissue variability, such as differentiating tumors and/or non-healthytissue from healthy tissue within an organ.

The control system 600 is configured for implementing a hyperspectralimaging and visualization system in which a molecular response isutilized to detect and identify anatomy in a surgical field of view. Thecontrol system 600 includes a conversion logic circuit 648 to converttissue data to surgeon usable information. For example, the variablereflectance based on wavelengths with respect to obscuring material canbe utilized to identify the critical structure in the anatomy. Moreover,the control system 600 combines the identified spectral signature andthe structural light data in an image. For example, the control system600 can be employed to create of three-dimensional data set for surgicaluse in a system with augmentation image overlays. Techniques can beemployed both intraoperatively and preoperatively using additionalvisual information. In various instances, the control system 600 isconfigured to provide warnings to a clinician when in the proximity ofone or more critical structures. Various algorithms can be employed toguide robotic automation and semi-automated approaches based on thesurgical procedure and proximity to the critical structure(s).

A projected array of lights is employed to determine tissue shape andmotion intraoperatively. Alternatively, flash Lidar may be utilized forsurface mapping of the tissue.

The control system 600 is configured to detect the critical structure(s)and provide an image overlay of the critical structure and measure thedistance to the surface of the visible tissue and the distance to theembedded/buried critical structure(s). In other instances, the controlsystem 600 can measure the distance to the surface of the visible tissueor detect the critical structure(s) and provide an image overlay of thecritical structure.

The control system 600 includes a spectral control circuit 602. Thespectral control circuit 602 can be a field programmable gate array(FPGA) or another suitable circuit configuration as described herein inconnection with FIGS. 2A-2C, for example. The spectral control circuit602 includes a processor 604 to receive video input signals from a videoinput processor 606. The processor 604 can be configured forhyperspectral processing and can utilize C/C++ code, for example. Thevideo input processor 606 receives video-in of control (metadata) datasuch as shutter time, wave length, and sensor analytics, for example.The processor 604 is configured to process the video input signal fromthe video input processor 606 and provide a video output signal to avideo output processor 608, which includes a hyperspectral video-out ofinterface control (metadata) data, for example. The video outputprocessor 608 provides the video output signal to an image overlaycontroller 610.

The video input processor 606 is coupled to a camera 612 at the patientside via a patient isolation circuit 614. As previously discussed, thecamera 612 includes a solid state image sensor 634. The patientisolation circuit can include a plurality of transformers so that thepatient is isolated from other circuits in the system. The camera 612receives intraoperative images through optics 632 and the image sensor634. The image sensor 634 can include a CMOS image sensor, for example,or may include any of the image sensor technologies discussed herein inconnection with FIG. 2 , for example. In one aspect, the camera 612outputs images in 14 bit/pixel signals. It will be appreciated thathigher or lower pixel resolutions may be employed without departing fromthe scope of the present disclosure. The isolated camera output signal613 is provided to a color RGB fusion circuit 616, which employs ahardware register 618 and a Nios2 co-processor 620 to process the cameraoutput signal 613. A color RGB fusion output signal is provided to thevideo input processor 606 and a laser pulsing control circuit 622.

The laser pulsing control circuit 622 controls a laser light engine 624.The laser light engine 624 outputs light in a plurality of wavelengths(λ₁, λ₂, λ₃ . . . λ_(n)) including near infrared (NIR). The laser lightengine 624 can operate in a plurality of modes. In one aspect, the laserlight engine 624 can operate in two modes, for example. In a first mode,e.g. a normal operating mode, the laser light engine 624 outputs anilluminating signal. In a second mode, e.g. an identification mode, thelaser light engine 624 outputs RGBG and NIR light. In various instances,the laser light engine 624 can operate in a polarizing mode.

Light output 626 from the laser light engine 624 illuminates targetedanatomy in an intraoperative surgical site 627. The laser pulsingcontrol circuit 622 also controls a laser pulse controller 628 for alaser pattern projector 630 that projects a laser light pattern 631,such as a grid or pattern of lines and/or dots, at a predeterminedwavelength (λ₂) on the operative tissue or organ at the surgical site627. The camera 612 receives the patterned light as well as thereflected light output through the camera optics 632. The image sensor634 converts the received light into a digital signal.

The color RGB fusion circuit 616 also outputs signals to the imageoverlay controller 610 and a video input module 636 for reading thelaser light pattern 631 projected onto the targeted anatomy at thesurgical site 627 by the laser pattern projector 630. A processingmodule 638 processes the laser light pattern 631 and outputs a firstvideo output signal 640 representative of the distance to the visibletissue at the surgical site 627. The data is provided to the imageoverlay controller 610. The processing module 638 also outputs a secondvideo signal 642 representative of a three-dimensional rendered shape ofthe tissue or organ of the targeted anatomy at the surgical site.

The first and second video output signals 640, 642 include datarepresentative of the position of the critical structure on athree-dimensional surface model, which is provided to an integrationmodule 643. In combination with data from the video out processor 608 ofthe spectral control circuit 602, the integration module 643 candetermine the distance d_(A) (FIG. 1 ) to a buried critical structure(e.g. via triangularization algorithms 644), and the distance d_(A) canbe provided to the image overlay controller 610 via a video outprocessor 646. The foregoing conversion logic can encompass theconversion logic circuit 648 intermediate video monitors 652 and thecamera 624/laser pattern projector 630 positioned at the surgical site627.

Preoperative data 650 from a CT or MRI scan can be employed to registeror align certain three-dimensional deformable tissue in variousinstances. Such preoperative data 650 can be provided to the integrationmodule 643 and ultimately to the image overlay controller 610 so thatsuch information can be overlaid with the views from the camera 612 andprovided to the video monitors 652. Registration of preoperative data isfurther described herein and in the aforementioned U.S. PatentApplications, including U.S. patent application Ser. No. 16/128,195,titled INTEGRATION OF IMAGING DATA, filed Sep. 11, 2018, now U.S. PatentApplication Publication No. 2020/0015907, for example, which areincorporated by reference herein in their respective entireties.

The video monitors 652 can output the integrated/augmented views fromthe image overlay controller 610. A clinician can select and/or togglebetween different views on one or more monitors. On a first monitor 652a, the clinician can toggle between (A) a view in which athree-dimensional rendering of the visible tissue is depicted and (B) anaugmented view in which one or more hidden critical structures aredepicted over the three-dimensional rendering of the visible tissue. Ona second monitor 652 b, the clinician can toggle on distancemeasurements to one or more hidden critical structures and/or thesurface of visible tissue, for example.

The control system 600 and/or various control circuits thereof can beincorporated into various surgical visualization systems disclosedherein.

FIG. 12 illustrates a structured (or patterned) light system 700,according to at least one aspect of the present disclosure. As describedherein, structured light in the form of stripes or lines, for example,can be projected from a light source and/or projector 706 onto thesurface 705 of targeted anatomy to identify the shape and contours ofthe surface 705. A camera 720, which can be similar in various respectsto the imaging device 120 (FIG. 1 ), for example, can be configured todetect the projected pattern of light on the surface 705. The way thatthe projected pattern deforms upon striking the surface 705 allowsvision systems to calculate the depth and surface information of thetargeted anatomy.

In certain instances, invisible (or imperceptible) structured light canbe utilized, in which the structured light is used without interferingwith other computer vision tasks for which the projected pattern may beconfusing. For example, infrared light or extremely fast frame rates ofvisible light that alternate between two exact opposite patterns can beutilized to prevent interference. Structured light is further describedat en.wikipedia.org/wiki/Structured_light.

As noted above, the various surgical visualization systems describedherein can be utilized to visualize various different types of tissuesand/or anatomical structures, including tissues and/or anatomicalstructures that may be obscured from being visualized by EMR in thevisible portion of the spectrum. In one aspect, the surgicalvisualization systems can utilize a spectral imaging system to visualizedifferent types of tissues based upon their varying combinations ofconstituent materials. In particular, a spectral imaging system can beconfigured to detect the presence of various constituent materialswithin a tissue being visualized based on the absorption coefficient ofthe tissue across various EMR wavelengths. The spectral imaging systemcan be further configured to characterize the tissue type of the tissuebeing visualized based upon the particular combination of constituentmaterials. To illustrate, FIG. 13A is a graph 2300 depicting how theabsorption coefficient of various biological materials varies across theEMR wavelength spectrum. In the graph 2300, the vertical axis 2303represents absorption coefficient of the biological material (e.g., incm⁻¹) and the horizontal axis 2304 represents EMR wavelength (e.g., inμm). The graph 2300 further illustrates a first line 2310 representingthe absorption coefficient of water at various EMR wavelengths, a secondline 2312 representing the absorption coefficient of protein at variousEMR wavelengths, a third line 2314 representing the absorptioncoefficient of melanin at various EMR wavelengths, a fourth line 2316representing the absorption coefficient of deoxygenated hemoglobin atvarious EMR wavelengths, a fifth line 2318 representing the absorptioncoefficient of oxygenated hemoglobin at various EMR wavelengths, and asixth line 2319 representing the absorption coefficient of collagen atvarious EMR wavelengths. Different tissue types have differentcombinations of constituent materials and, therefore, the tissue type(s)being visualized by a surgical visualization system can be identifiedand differentiated between according to the particular combination ofdetected constituent materials. Accordingly, a spectral imaging systemcan be configured to emit EMR at a number of different wavelengths,determine the constituent materials of the tissue based on the detectedabsorption EMR absorption response at the different wavelengths, andthen characterize the tissue type based on the particular detectedcombination of constituent materials.

An illustration of the utilization of spectral imaging techniques tovisualize different tissue types and/or anatomical structures is shownin FIG. 13B. In FIG. 13B, a spectral emitter 2320 (e.g., spectral lightsource 150) is being utilized by an imaging system to visualize asurgical site 2325. The EMR emitted by the spectral emitter 2320 andreflected from the tissues and/or structures at the surgical site 2325can be received by an image sensor 135 (FIG. 2 ) to visualize thetissues and/or structures, which can be either visible (e.g., be locatedat the surface of the surgical site 2325) or obscured (e.g., underlayother tissue and/or structures at the surgical site 2325). In thisexample, an imaging system 142 (FIG. 2 ) can visualize a tumor 2332, anartery 2334, and various abnormalities 2338 (i.e., tissues notconfirming to known or expected spectral signatures) based upon thespectral signatures characterized by the differing absorptivecharacteristics (e.g., absorption coefficient) of the constituentmaterials for each of the different tissue/structure types. Thevisualized tissues and structures can be displayed on a display screenassociated with or coupled to the imaging system 142, such as an imagingsystem display 146 (FIG. 2 ), a primary display 2119 (FIG. 18 ), anon-sterile display 2109 (FIG. 18 ), a hub display 2215 (FIG. 19 ), adevice/instrument display 2237 (FIG. 19 ), and so on.

Further, the imaging system 142 can be configured to tailor or updatethe displayed surgical site visualization according to the identifiedtissue and/or structure types. For example, the imaging system 142 candisplay a margin 2330 a associated with the tumor 2332 being visualizedon a display screen (e.g., display 146). The margin 2330 a can indicatethe area or amount of tissue that should be excised to ensure completeremoval of the tumor 2332. The control system 133 (FIG. 2 ) can beconfigured to control or update the dimensions of the margin 2330 abased on the tissues and/or structures identified by the imaging system142. In the illustrated example, the imaging system 142 has identifiedmultiple abnormalities 2338 within the FOV. Accordingly, the controlsystem 133 can adjust the displayed margin 2330 a to a first updatedmargin 2330 b having sufficient dimensions to encompass theabnormalities 2338. Further, the imaging system 142 has also identifiedan artery 2334 partially overlapping with the initially displayed margin2330 a (as indicated by the highlighted region 2336 of the artery 2334).Accordingly, the control system 133 can adjust the displayed margin 2330a to a second updated margin 2330 c having sufficient dimensions toencompass the relevant portion of the artery 2334.

Tissues and/or structures can also be imaged or characterized accordingto their reflective characteristics, in addition to or in lieu of theirabsorptive characteristics described above with respect to FIGS. 13A and13B, across the EMR wavelength spectrum. For example, FIGS. 13C-13Eillustrate various graphs of reflectance of different types of tissuesor structures across different EMR wavelengths. FIG. 13C is a graphicalrepresentation 1050 of an illustrative ureter signature versusobscurants. FIG. 13D is a graphical representation 1052 of anillustrative artery signature versus obscurants. FIG. 13E is a graphicalrepresentation 1054 of an illustrative nerve signature versusobscurants. The plots in FIGS. 13C-13E represent reflectance as afunction of wavelength (nm) for the particular structures (ureter,artery, and nerve) relative to the corresponding reflectances of fat,lung tissue, and blood at the corresponding wavelengths. These graphsare simply for illustrative purposes and it should be understood thatother tissues and/or structures could have corresponding detectablereflectance signatures that would allow the tissues and/or structures tobe identified and visualized.

In various instances, select wavelengths for spectral imaging can beidentified and utilized based on the anticipated critical structuresand/or obscurants at a surgical site (i.e., “selective spectral”imaging). By utilizing selective spectral imaging, the amount of timerequired to obtain the spectral image can be minimized such that theinformation can be obtained in real-time, or near real-time, andutilized intraoperatively. In various instances, the wavelengths can beselected by a clinician or by a control circuit based on input by theclinician. In certain instances, the wavelengths can be selected basedon machine learning and/or big data accessible to the control circuitvia a cloud, for example.

The foregoing application of spectral imaging to tissue can be utilizedintraoperatively to measure the distance between a waveform emitter anda critical structure that is obscured by tissue. In one aspect of thepresent disclosure, referring now to FIGS. 14 and 15 , a time-of-flightsensor system 1104 utilizing waveforms 1124, 1125 is shown. Thetime-of-flight sensor system 1104 can be incorporated into the surgicalvisualization system 100 (FIG. 1 ) in certain instances. Thetime-of-flight sensor system 1104 includes a waveform emitter 1106 and awaveform receiver 1108 on the same surgical device 1102. The emittedwave 1124 extends to the critical structure 1101 from the emitter 1106and the received wave 1125 is reflected back to by the receiver 1108from the critical structure 1101. The surgical device 1102 is positionedthrough a trocar 1110 that extends into a cavity 1107 in a patient.

The waveforms 1124, 1125 are configured to penetrate obscuring tissue1103. For example, the wavelengths of the waveforms 1124, 1125 can be inthe NIR or SWIR spectrum of wavelengths. In one aspect, a spectralsignal (e.g. hyperspectral, multispectral, or selective spectral) or aphotoacoustic signal can be emitted from the emitter 1106 and canpenetrate the tissue 1103 in which the critical structure 1101 isconcealed. The emitted waveform 1124 can be reflected by the criticalstructure 1101. The received waveform 1125 can be delayed due to thedistance d between the distal end of the surgical device 1102 and thecritical structure 1101. In various instances, the waveforms 1124, 1125can be selected to target the critical structure 1101 within the tissue1103 based on the spectral signature of the critical structure 1101, asfurther described herein. In various instances, the emitter 1106 isconfigured to provide a binary signal on and off, as shown in FIG. 15 ,for example, which can be measured by the receiver 1108.

Based on the delay between the emitted wave 1124 and the received wave1125, the time-of-flight sensor system 1104 is configured to determinethe distance d (FIG. 14 ). A time-of-flight timing diagram 1130 for theemitter 1106 and the receiver 1108 of FIG. 14 is shown in FIG. 15 . Thedelay is a function of the distance d and the distance d is given by:

$d = {\frac{ct}{2} \cdot \frac{q_{2}}{q_{1} + q_{2}}}$where:

-   -   c=the speed of light;    -   t=length of pulse;    -   q₁=accumulated charge while light is emitted; and    -   q₂=accumulated charge while light is not being emitted.

As provided herein, the time-of-flight of the waveforms 1124, 1125corresponds to the distance din FIG. 14 . In various instances,additional emitters/receivers and/or pulsing signals from the emitter1106 can be configured to emit a non-penetrating signal. Thenon-penetrating tissue can be configured to determine the distance fromthe emitter to the surface 1105 of the obscuring tissue 1103. In variousinstances, the depth of the critical structure 1101 can be determinedby:d _(A) =d _(w) −d _(t).where:

-   -   d_(A)=the depth of the critical structure 1101;    -   d_(w)=the distance from the emitter 1106 to the critical        structure 1101 (din FIG. 14 ); and    -   d_(t)=the distance from the emitter 1106 (on the distal end of        the surgical device 1102) to the surface 1105 of the obscuring        tissue 1103.

In one aspect of the present disclosure, referring now to FIG. 16 , atime-of-flight sensor system 1204 utilizing waves 1224 a, 1224 b, 1224c, 1225 a, 1225 b, 1225 c is shown. The time-of-flight sensor system1204 can be incorporated into the surgical visualization system 100(FIG. 1 ) in certain instances. The time-of-flight sensor system 1204includes a waveform emitter 1206 and a waveform receiver 1208. Thewaveform emitter 1206 is positioned on a first surgical device 1202 a,and the waveform receiver 1208 is positioned on a second surgical device1202 b. The surgical devices 1202 a, 1202 b are positioned through theirrespective trocars 1210 a, 1210 b, respectively, which extend into acavity 1207 in a patient. The emitted waves 1224 a, 1224 b, 1224 cextend toward a surgical site from the emitter 1206 and the receivedwaves 1225 a, 1225 b, 1225 c are reflected back to the −receiver 1208from various structures and/or surfaces at the surgical site.

The different emitted waves 1224 a, 1224 b, 1224 c are configured totarget different types of material at the surgical site. For example,the wave 1224 a targets the obscuring tissue 1203, the wave 1224 btargets a first critical structure 1201 a (e.g. a vessel), and the wave1224 c targets a second critical structure 1201 b (e.g. a canceroustumor). The wavelengths of the waves 1224 a, 1224 b, 1224 c can be inthe visible light, NIR, or SWIR spectrum of wavelengths. For example,visible light can be reflected off a surface 1205 of the tissue 1203 andNIR and/or SWIR waveforms can be configured to penetrate the surface1205 of the tissue 1203. In various aspects, as described herein, aspectral signal (e.g. hyperspectral, multispectral, or selectivespectral) or a photoacoustic signal can be emitted from the emitter1206. In various instances, the waves 1224 b, 1224 c can be selected totarget the critical structures 1201 a, 1201 b within the tissue 1203based on the spectral signature of the critical structure 1201 a, 1201b, as further described herein. Photoacoustic imaging is furtherdescribed in various U.S. Patent Applications, which are incorporated byreference herein in the present disclosure.

The emitted waves 1224 a, 1224 b, 1224 c can be reflected off thetargeted material (i.e. the surface 1205, the first critical structure1201 a, and the second structure 1201 b, respectively). The receivedwaveforms 1225 a, 1225 b, 1225 c can be delayed due to the distancesd_(1a), d_(2a), d_(3a), d_(1b), d_(2b), d_(2c) indicated in FIG. 16 .

In the time-of-flight sensor system 1204, in which the emitter 1206 andthe receiver 1208 are independently positionable (e.g., on separatesurgical devices 1202 a, 1202 b and/or controlled by separate roboticarms), the various distances d_(1a), d_(2a), d_(3a), d_(1b), d_(2b),d_(2c) can be calculated from the known position of the emitter 1206 andthe receiver 1208. For example, the positions can be known when thesurgical devices 1202 a, 1202 b are robotically-controlled. Knowledge ofthe positions of the emitter 1206 and the receiver 1208, as well as thetime of the photon stream to target a certain tissue and the informationreceived by the receiver 1208 of that particular response can allow adetermination of the distances d_(1a), d_(2a), d_(3a), d_(1b), d_(2b),d_(2c). In one aspect, the distance to the obscured critical structures1201 a, 1201 b can be triangulated using penetrating wavelengths.Because the speed of light is constant for any wavelength of visible orinvisible light, the time-of-flight sensor system 1204 can determine thevarious distances.

Referring still to FIG. 16 , in various instances, in the view providedto the clinician, the receiver 1208 can be rotated such that the centerof mass of the target structure in the resulting images remainsconstant, i.e., in a plane perpendicular to the axis of a select targetstructures 1203, 1201 a, or 1201 b. Such an orientation can quicklycommunicate one or more relevant distances and/or perspectives withrespect to the critical structure. For example, as shown in FIG. 16 ,the surgical site is displayed from a viewpoint in which the criticalstructure 1201 a is perpendicular to the viewing plane (i.e. the vesselis oriented in/out of the page). In various instances, such anorientation can be default setting; however, the view can be rotated orotherwise adjusted by a clinician. In certain instances, the cliniciancan toggle between different surfaces and/or target structures thatdefine the viewpoint of the surgical site provided by the imagingsystem.

In various instances, the receiver 1208 can be mounted on a trocar orcannula, such as the trocar 1210 b, for example, through which thesurgical device 1202 b is positioned. In other instances, the receiver1208 can be mounted on a separate robotic arm for which thethree-dimensional position is known. In various instances, the receiver1208 can be mounted on a movable arm that is separate from the robotthat controls the surgical device 1202 a or can be mounted to anoperating room (OR) table that is intraoperatively registerable to therobot coordinate plane. In such instances, the position of the emitter1206 and the receiver 1208 can be registerable to the same coordinateplane such that the distances can be triangulated from outputs from thetime-of-flight sensor system 1204.

Combining time-of-flight sensor systems and near-infrared spectroscopy(NIRS), termed TOF-NIRS, which is capable of measuring the time-resolvedprofiles of NIR light with nanosecond resolution can be found in thearticle titled TIME-OF-FLIGHT NEAR-INFRARED SPECTROSCOPY FORNONDESTRUCTIVE MEASUREMENT OF INTERNAL QUALITY IN GRAPEFRUIT, in theJournal of the American Society for Horticultural Science, May 2013,Vol. 138, No. 3, 225-228, which is incorporated by reference herein inits entirety, and is accessible atjournal.ashspublications.org/content/138/3/225.full.

In various instances, time-of-flight spectral waveforms are configuredto determine the depth of the critical structure and/or the proximity ofa surgical device to the critical structure. Moreover, the varioussurgical visualization systems disclosed herein include surface mappinglogic that is configured to create three-dimensional rendering of thesurface of the visible tissue. In such instances, even when the visibletissue obstructs a critical structure, the clinician can be aware of theproximity (or lack thereof) of a surgical device to the criticalstructure. In one instances, the topography of the surgical site isprovided on a monitor by the surface mapping logic. If the criticalstructure is close to the surface of the tissue, spectral imaging canconvey the position of the critical structure to the clinician. Forexample, spectral imaging may detect structures within 5 or 10 mm of thesurface. In other instances, spectral imaging may detect structures 10or 20 mm below the surface of the tissue. Based on the known limits ofthe spectral imaging system, the system is configured to convey that acritical structure is out-of-range if it is simply not detected by thespectral imaging system. Therefore, the clinician can continue to movethe surgical device and/or manipulate the tissue. When the criticalstructure moves into range of the spectral imaging system, the systemcan identify the structure and, thus, communicate that the structure iswithin range. In such instances, an alert can be provided when astructure is initially identified and/or moved further within apredefined proximity zone. In such instances, even non-identification ofa critical structure by a spectral imaging system with knownbounds/ranges can provide proximity information (i.e. the lack ofproximity) to the clinician.

Various surgical visualization systems disclosed herein can beconfigured to identify intraoperatively the presence of and/or proximityto critical structure(s) and to alert a clinician prior to damaging thecritical structure(s) by inadvertent dissection and/or transection. Invarious aspects, the surgical visualization systems are configured toidentify one or more of the following critical structures: ureters,bowel, rectum, nerves (including the phrenic nerve, recurrent laryngealnerve [RLN], promontory facial nerve, vagus nerve, and branchesthereof), vessels (including the pulmonary and lobar arteries and veins,inferior mesenteric artery [IMA] and branches thereof, superior rectalartery, sigmoidal arteries, and left colic artery), superior mesentericartery (SMA) and branches thereof (including middle colic artery, rightcolic artery, ilecolic artery), hepatic artery and branches thereof,portal vein and branches thereof, splenic artery/vein and branchesthereof, external and internal (hypogastric) ileac vessels, shortgastric arteries, uterine arteries, middle sacral vessels, and lymphnodes, for example. Moreover, the surgical visualization systems areconfigured to indicate proximity of surgical device(s) to the criticalstructure(s) and/or warn the clinician when surgical device(s) aregetting close to the critical structure(s).

Various aspects of the present disclosure provide intraoperativecritical structure identification (e.g., identification of ureters,nerves, and/or vessels) and instrument proximity monitoring. Forexample, various surgical visualization systems disclosed herein caninclude spectral imaging and surgical instrument tracking, which enablethe visualization of critical structures below the surface of thetissue, such as 1.0-1.5 cm below the surface of the tissue, for example.In other instances, the surgical visualization system can identifystructures less than 1.0 cm or more the 1.5 cm below the surface of thetissue. For example, even a surgical visualization system that canidentify structures only within 0.2 mm of the surface, for example, canbe valuable if the structure cannot otherwise be seen due to the depth.In various aspects, the surgical visualization system can augment theclinician's view with a virtual depiction of the critical structure as avisible white-light image overlay on the surface of visible tissue, forexample. The surgical visualization system can provide real-time,three-dimensional spatial tracking of the distal tip of surgicalinstruments and can provide a proximity alert when the distal tip of asurgical instrument moves within a certain range of the criticalstructure, such as within 1.0 cm of the critical structure, for example.

Various surgical visualization systems disclosed herein can identifywhen dissection is too close to a critical structure. Dissection may be“too close” to a critical structure based on the temperature (i.e. toohot within a proximity of the critical structure that may riskdamaging/heating/melting the critical structure) and/or based on tension(i.e. too much tension within a proximity of the critical structure thatmay risk damaging/tearing/pulling the critical structure). Such asurgical visualization system can facilitate dissection around vesselswhen skeletonizing the vessels prior to ligation, for example. Invarious instances, a thermal imaging camera can be utilized to read theheat at the surgical site and provide a warning to the clinician that isbased on the detected heat and the distance from a tool to thestructure. For example, if the temperature of the tool is over apredefined threshold (such as 120 degrees F., for example), an alert canbe provided to the clinician at a first distance (such as 10 mm, forexample), and if the temperature of the tool is less than or equal tothe predefined threshold, the alert can be provided to the clinician ata second distance (such as 5 mm, for example). The predefined thresholdsand/or warning distances can be default settings and/or programmable bythe clinician. Additionally or alternatively, a proximity alert can belinked to thermal measurements made by the tool itself, such as athermocouple that measures the heat in a distal jaw of a monopolar orbipolar dissector or vessel sealer, for example.

Various surgical visualization systems disclosed herein can provideadequate sensitivity with respect to a critical structure andspecificity to enable a clinician to proceed with confidence in a quickbut safe dissection based on the standard of care and/or device safetydata. The system can function intraoperatively and in real-time during asurgical procedure with minimal ionizing radiation risk to a patient ora clinician and, in various instances, no risk of ionizing radiationrisk to the patient or the clinician. Conversely, in a fluoroscopyprocedure, the patient and clinician(s) may be exposed to ionizingradiation via an X-ray beam, for example, that is utilized to view theanatomical structures in real-time.

Various surgical visualization systems disclosed herein can beconfigured to detect and identify one or more desired types of criticalstructures in a forward path of a surgical device, such as when the pathof the surgical device is robotically controlled, for example.Additionally or alternatively, the surgical visualization system can beconfigured to detect and identify one or more types of criticalstructures in a surrounding area of the surgical device and/or inmultiple planes/dimensions, for example.

Various surgical visualization systems disclosed herein can be easy tooperate and/or interpret. Moreover, various surgical visualizationsystems can incorporate an “override” feature that allows the clinicianto override a default setting and/or operation. For example, a cliniciancan selectively turn off alerts from the surgical visualization systemand/or get closer to a critical structure than suggested by the surgicalvisualization system such as when the risk to the critical structure isless than risk of avoiding the area (e.g. when removing cancer around acritical structure the risk of leaving the cancerous tissue can begreater than the risk of damage to the critical structure).

Various surgical visualization systems disclosed herein can beincorporated into a surgical system and/or used during a surgicalprocedure with limited impact to the workflow. In other words,implementation of the surgical visualization system may not change theway the surgical procedure is implemented. Moreover, the surgicalvisualization system can be economical in comparison to the costs of aninadvertent transection. Data indicates the reduction in inadvertentdamage to a critical structure can drive incremental reimbursement.

Various surgical visualization systems disclosed herein can operate inreal-time, or near real-time, and far enough in advance to enable aclinician to anticipate critical structure(s). For example, a surgicalvisualization system can provide enough time to “slow down, evaluate,and avoid” in order to maximize efficiency of the surgical procedure.

Various surgical visualization systems disclosed herein may not requirea contrast agent, or dye, that is injected into tissue. For example,spectral imaging is configured to visualize hidden structuresintraoperatively without the use of a contrast agent or dye. In otherinstances, the contrast agent can be easier to inject into the properlayer(s) of tissue than other visualization systems. The time betweeninjection of the contrast agent and visualization of the criticalstructure can be less than two hours, for example.

Various surgical visualization systems disclosed herein can be linkedwith clinical data and/or device data. For example, data can provideboundaries for how close energy-enabled surgical devices (or otherpotentially damaging devices) should be from tissue that the surgeondoes not want to damage. Any data modules that interface with thesurgical visualization systems disclosed herein can be providedintegrally or separately from a robot to enable use with stand-alonesurgical devices in open or laparoscopic procedures, for example. Thesurgical visualization systems can be compatible with robotic surgicalsystems in various instances. For example, the visualizationimages/information can be displayed in a robotic console.

In various instances, clinicians may not know the location of a criticalstructure with respect to a surgical tool. For example, when a criticalstructure is embedded in tissue, the clinician may be unable toascertain the location of the critical structure. In certain instances,a clinician may want to keep a surgical device outside a range ofpositions surrounding the critical structure and/or away from thevisible tissue covering the hidden critical structure. When the locationof a concealed critical structure is unknown, the clinician may riskmoving too close to the critical structure, which can result ininadvertent trauma and/or dissection of the critical structure and/ortoo much energy, heat, and/or tension in proximity of the criticalstructure. Alternatively, the clinician may stay too far away from asuspected location of the critical structure and risk affecting tissueat a less desirable location in an effort to avoid the criticalstructure.

A surgical visualization system is provided that presents surgicaldevice tracking with respect to one or more critical structures. Forexample, the surgical visualization system can track the proximity of asurgical device with respect to a critical structure. Such tracking canoccur intraoperatively, in real-time, and/or in near real-time. Invarious instances, the tracking data can be provided to the cliniciansvia a display screen (e.g. a monitor) of an imaging system.

In one aspect of the present disclosure, a surgical visualization systemincludes a surgical device comprising an emitter configured to emit astructured light pattern onto a visible surface, an imaging systemcomprising a camera configured to detect an embedded structure and thestructured light pattern on the visible surface, and a control circuitin signal communication with the camera and the imaging system, whereinthe control circuit is configured to determine a distance from thesurgical device to the embedded structure and provide a signal to theimaging system indicative of the distance. For example, the distance canbe determined by computing a distance from the camera to the criticalstructure that is illuminated with fluoroscopy technology and based on athree-dimensional view of the illuminated structure provided by imagesfrom multiple lenses (e.g. a left-side lens and a right-side lens) ofthe camera. The distance from the surgical device to the criticalstructure can be triangulated based on the known positions of thesurgical device and the camera, for example. Alternative means fordetermining the distance to an embedded critical structure are furtherdescribed herein. For example, NIR time-of-flight distance sensors canbe employed. Additionally or alternatively, the surgical visualizationsystem can determine a distance to visible tissue overlying/covering anembedded critical structure. For example, the surgical visualizationsystem can identify a hidden critical structure and augment a view ofthe hidden critical structure by depicting a schematic of the hiddencritical structure on the visible structure, such as a line on thesurface of the visible tissue. The surgical visualization system canfurther determine the distance to the augmented line on the visibletissue.

By providing the clinician with up-to-date information regarding theproximity of the surgical device to the concealed critical structureand/or visible structure, as provided by the various surgicalvisualization systems disclosed herein, the clinician can make moreinformed decisions regarding the placement of the surgical devicerelative to the concealed critical structure. For example, the cliniciancan view the distance between the surgical device and the criticalstructure in real-time/intraoperatively and, in certain instances, analert and/or warning can be provided by the imaging system when thesurgical device is moved within a predefined proximity and/or zone ofthe critical structure. In certain instances, the alert and/or warningcan be provided when the trajectory of the surgical device indicates alikely collision with a “no-fly” zone in the proximity of the criticalstructure (e.g. within 1 mm, 2 mm, 5 mm, 10 mm, 20 mm or more of thecritical structure). In such instances, the clinician can maintainmomentum throughout the surgical procedure without requiring theclinician to monitor a suspected location of the critical structure andthe surgical device's proximity thereto. As a result, certain surgicalprocedures can be performed more quickly, with fewerpauses/interruptions, and/or with improved accuracy and/or certainty,for example. In one aspect, the surgical visualization system can beutilized to detect tissue variability, such as the variability of tissuewithin an organ to differentiate tumors/cancerous tissue/unhealthytissue from healthy tissue. Such a surgical visualization system canmaximize the removal of the unhealthy tissue while minimizing theremoval of the healthy tissue.

Surgical Hub System

The various visualization or imaging systems described herein can beincorporated into a surgical hub system, such as is illustrated inconnection with FIGS. 17-19 and described in further detail below.

Referring to FIG. 17 , a computer-implemented interactive surgicalsystem 2100 includes one or more surgical systems 2102 and a cloud-basedsystem (e.g., the cloud 2104 that may include a remote server 2113coupled to a storage device 2105). Each surgical system 2102 includes atleast one surgical hub 2106 in communication with the cloud 2104 thatmay include a remote server 2113. In one example, as illustrated in FIG.17 , the surgical system 2102 includes a visualization system 2108, arobotic system 2110, and a handheld intelligent surgical instrument2112, which are configured to communicate with one another and/or thehub 2106. In some aspects, a surgical system 2102 may include an Mnumber of hubs 2106, an N number of visualization systems 2108, an Onumber of robotic systems 2110, and a P number of handheld intelligentsurgical instruments 2112, where M, N, O, and P are integers greaterthan or equal to one.

FIG. 18 depicts an example of a surgical system 2102 being used toperform a surgical procedure on a patient who is lying down on anoperating table 2114 in a surgical operating room 2116. A robotic system2110 is used in the surgical procedure as a part of the surgical system2102. The robotic system 2110 includes a surgeon's console 2118, apatient side cart 2120 (surgical robot), and a surgical robotic hub2122. The patient side cart 2120 can manipulate at least one removablycoupled surgical tool 2117 through a minimally invasive incision in thebody of the patient while the surgeon views the surgical site throughthe surgeon's console 2118. An image of the surgical site can beobtained by a medical imaging device 2124, which can be manipulated bythe patient side cart 2120 to orient the imaging device 2124. Therobotic hub 2122 can be used to process the images of the surgical sitefor subsequent display to the surgeon through the surgeon's console2118.

Other types of robotic systems can be readily adapted for use with thesurgical system 2102. Various examples of robotic systems and surgicaltools that are suitable for use with the present disclosure aredescribed in various U.S. Patent Applications, which are incorporated byreference herein in the present disclosure.

Various examples of cloud-based analytics that are performed by thecloud 2104, and are suitable for use with the present disclosure, aredescribed in various U.S. Patent Applications, which are incorporated byreference herein in the present disclosure.

In various aspects, the imaging device 2124 includes at least one imagesensor and one or more optical components. Suitable image sensorsinclude, but are not limited to, Charge-Coupled Device (CCD) sensors andComplementary Metal-Oxide Semiconductor (CMOS) sensors.

The optical components of the imaging device 2124 may include one ormore illumination sources and/or one or more lenses. The one or moreillumination sources may be directed to illuminate portions of thesurgical field. The one or more image sensors may receive lightreflected or refracted from the surgical field, including lightreflected or refracted from tissue and/or surgical instruments.

The one or more illumination sources may be configured to radiateelectromagnetic energy in the visible spectrum as well as the invisiblespectrum. The visible spectrum, sometimes referred to as the opticalspectrum or luminous spectrum, is that portion of the electromagneticspectrum that is visible to (i.e., can be detected by) the human eye andmay be referred to as visible light or simply light. A typical human eyewill respond to wavelengths in air that are from about 380 nm to about750 nm.

The invisible spectrum (i.e., the non-luminous spectrum) is that portionof the electromagnetic spectrum that lies below and above the visiblespectrum (i.e., wavelengths below about 380 nm and above about 750 nm).The invisible spectrum is not detectable by the human eye. Wavelengthsgreater than about 750 nm are longer than the red visible spectrum, andthey become invisible infrared (IR), microwave, and radioelectromagnetic radiation. Wavelengths less than about 380 nm areshorter than the violet spectrum, and they become invisible ultraviolet,x-ray, and gamma ray electromagnetic radiation.

In various aspects, the imaging device 2124 is configured for use in aminimally invasive procedure. Examples of imaging devices suitable foruse with the present disclosure include, but not limited to, anarthroscope, angioscope, bronchoscope, choledochoscope, colonoscope,cytoscope, duodenoscope, enteroscope, esophagogastro-duodenoscope(gastroscope), endoscope, laryngoscope, nasopharyngo-neproscope,sigmoidoscope, thoracoscope, and ureteroscope.

In one aspect, the imaging device employs multi-spectrum monitoring todiscriminate topography and underlying structures. A multi-spectralimage is one that captures image data within specific wavelength rangesacross the electromagnetic spectrum. The wavelengths may be separated byfilters or by the use of instruments that are sensitive to particularwavelengths, including light from frequencies beyond the visible lightrange, e.g., IR and ultraviolet. Spectral imaging can allow extractionof additional information the human eye fails to capture with itsreceptors for red, green, and blue. The use of multi-spectral imaging isdescribed in various U.S. Patent Applications that are incorporated byreference herein in the present disclosure. Multi-spectrum monitoringcan be a useful tool in relocating a surgical field after a surgicaltask is completed to perform one or more of the previously describedtests on the treated tissue.

It is axiomatic that strict sterilization of the operating room andsurgical equipment is required during any surgery. The strict hygieneand sterilization conditions required in a “surgical theater,” i.e., anoperating or treatment room, necessitate the highest possible sterilityof all medical devices and equipment. Part of that sterilization processis the need to sterilize anything that comes in contact with the patientor penetrates the sterile field, including the imaging device 2124 andits attachments and components. It will be appreciated that the sterilefield may be considered a specified area, such as within a tray or on asterile towel, that is considered free of microorganisms, or the sterilefield may be considered an area, immediately around a patient, who hasbeen prepared for a surgical procedure. The sterile field may includethe scrubbed team members, who are properly attired, and all furnitureand fixtures in the area. In various aspects, the visualization system2108 includes one or more imaging sensors, one or more image-processingunits, one or more storage arrays, and one or more displays that arestrategically arranged with respect to the sterile field, as illustratedin FIG. 18 . In one aspect, the visualization system 2108 includes aninterface for HL7, PACS, and EMR. Various components of thevisualization system 2108 are described in various U.S. PatentApplications that are incorporated by reference herein in the presentdisclosure.

As illustrated in FIG. 18 , a primary display 2119 is positioned in thesterile field to be visible to an operator at the operating table 2114.In addition, a visualization tower 21121 is positioned outside thesterile field. The visualization tower 21121 includes a firstnon-sterile display 2107 and a second non-sterile display 2109, whichface away from each other. The visualization system 2108, guided by thehub 2106, is configured to utilize the displays 2107, 2109, and 2119 tocoordinate information flow to operators inside and outside the sterilefield. For example, the hub 2106 may cause the visualization system 2108to display a snapshot of a surgical site, as recorded by an imagingdevice 2124, on a non-sterile display 2107 or 2109, while maintaining alive feed of the surgical site on the primary display 2119. The snapshoton the non-sterile display 2107 or 2109 can permit a non-sterileoperator to perform a diagnostic step relevant to the surgicalprocedure, for example.

In one aspect, the hub 2106 is also configured to route a diagnosticinput or feedback entered by a non-sterile operator at the visualizationtower 21121 to the primary display 2119 within the sterile field, whereit can be viewed by a sterile operator at the operating table. In oneexample, the input can be in the form of a modification to the snapshotdisplayed on the non-sterile display 2107 or 2109, which can be routedto the primary display 2119 by the hub 2106.

Referring to FIG. 18 , a surgical instrument 2112 is being used in thesurgical procedure as part of the surgical system 2102. The hub 2106 isalso configured to coordinate information flow to a display of thesurgical instrument 2112, as is described in various U.S. PatentApplications that are incorporated by reference herein in the presentdisclosure. A diagnostic input or feedback entered by a non-sterileoperator at the visualization tower 21121 can be routed by the hub 2106to the surgical instrument display 2115 within the sterile field, whereit can be viewed by the operator of the surgical instrument 2112.Example surgical instruments that are suitable for use with the surgicalsystem 2102 are described in various U.S. Patent Applications that areincorporated by reference herein in the present disclosure.

FIG. 19 illustrates a computer-implemented interactive surgical system2200. The computer-implemented interactive surgical system 2200 issimilar in many respects to the computer-implemented interactivesurgical system 2100. The surgical system 2200 includes at least onesurgical hub 2236 in communication with a cloud 2204 that may include aremote server 2213. In one aspect, the computer-implemented interactivesurgical system 2200 comprises a surgical hub 2236 connected to multipleoperating theater devices such as, for example, intelligent surgicalinstruments, robots, and other computerized devices located in theoperating theater. The surgical hub 2236 comprises a communicationsinterface for communicably coupling the surgical hub 2236 to the cloud2204 and/or remote server 2213. As illustrated in the example of FIG. 19, the surgical hub 2236 is coupled to an imaging module 2238 that iscoupled to an endoscope 2239, a generator module 2240 that is coupled toan energy device 2421, a smoke evacuator module 2226, asuction/irrigation module 2228, a communication module 2230, a processormodule 2232, a storage array 2234, a smart device/instrument 2235optionally coupled to a display 2237, and a non-contact sensor module2242. The operating theater devices are coupled to cloud computingresources and data storage via the surgical hub 2236. A robot hub 2222also may be connected to the surgical hub 2236 and to the cloudcomputing resources. The devices/instruments 2235, visualization systems2209, among others, may be coupled to the surgical hub 2236 via wired orwireless communication standards or protocols, as described herein. Thesurgical hub 2236 may be coupled to a hub display 2215 (e.g., monitor,screen) to display and overlay images received from the imaging module,device/instrument display, and/or other visualization systems 208. Thehub display also may display data received from devices connected to themodular control tower in conjunction with images and overlaid images.

Situational Awareness

The various visualization systems or aspects of visualization systemsdescribed herein can be utilized as part of a situational awarenesssystem that can be embodied or executed by a surgical hub 2106, 2236(FIGS. 17-19 ). In particular, characterizing, identifying, and/orvisualizing surgical instruments or other surgical devices (includingtheir positions, orientations, and actions), tissues, structures, users,and other things located within the surgical field or the operatingtheater can provide contextual data that can be utilized by asituational awareness system to infer the type of surgical procedure ora step thereof being performed, the type of tissue(s) and/orstructure(s) being manipulated by the surgeon, and so on. Thiscontextual data can then be utilized by the situational awareness systemto provide alerts to users, suggest subsequent steps or actions for theusers to undertake, prepare surgical devices in anticipation for theiruse (e.g., activate an electrosurgical generator in anticipation of anelectrosurgical instrument being utilized in a subsequent step of thesurgical procedure), control surgical instruments intelligently (e.g.,customize surgical instrument operational parameters based on eachpatient's particular health profile), and so on.

Although an “intelligent” device including control algorithms thatrespond to sensed data can be an improvement over a “dumb” device thatoperates without accounting for sensed data, some sensed data can beincomplete or inconclusive when considered in isolation, i.e., withoutthe context of the type of surgical procedure being performed or thetype of tissue that is being operated on. Without knowing the proceduralcontext (e.g., knowing the type of tissue being operated on or the typeof procedure being performed), the control algorithm may control modulardevice incorrectly or suboptimally given the particular context-freesensed data. Modular devices can include any surgical devices that iscontrollable by a situational awareness system, such as visualizationsystem devices (e.g., a camera or display screen), surgical instruments(e.g., an ultrasonic surgical instrument, an electrosurgical instrument,or a surgical stapler), and other surgical devices (e.g., a smokeevacuator). For example, the optimal manner for a control algorithm tocontrol a surgical instrument in response to a particular sensedparameter can vary according to the particular tissue type beingoperated on. This is due to the fact that different tissue types havedifferent properties (e.g., resistance to tearing) and thus responddifferently to actions taken by surgical instruments. Therefore, it maybe desirable for a surgical instrument to take different actions evenwhen the same measurement for a particular parameter is sensed. As onespecific example, the optimal manner in which to control a surgicalstapling and cutting instrument in response to the instrument sensing anunexpectedly high force to close its end effector will vary dependingupon whether the tissue type is susceptible or resistant to tearing. Fortissues that are susceptible to tearing, such as lung tissue, theinstrument's control algorithm would optimally ramp down the motor inresponse to an unexpectedly high force to close to avoid tearing thetissue. For tissues that are resistant to tearing, such as stomachtissue, the instrument's control algorithm would optimally ramp up themotor in response to an unexpectedly high force to close to ensure thatthe end effector is clamped properly on the tissue. Without knowingwhether lung or stomach tissue has been clamped, the control algorithmmay make a suboptimal decision.

One solution utilizes a surgical hub including a system that isconfigured to derive information about the surgical procedure beingperformed based on data received from various data sources and thencontrol the paired modular devices accordingly. In other words, thesurgical hub is configured to infer information about the surgicalprocedure from received data and then control the modular devices pairedto the surgical hub based upon the inferred context of the surgicalprocedure. FIG. 20 illustrates a diagram of a situationally awaresurgical system 2400, in accordance with at least one aspect of thepresent disclosure. In some exemplifications, the data sources 2426include, for example, the modular devices 2402 (which can includesensors configured to detect parameters associated with the patientand/or the modular device itself), databases 2422 (e.g., an EMR databasecontaining patient records), and patient monitoring devices 2424 (e.g.,a blood pressure (BP) monitor and an electrocardiography (EKG) monitor).

A surgical hub 2404, which may be similar to the hub 106 in manyrespects, can be configured to derive the contextual informationpertaining to the surgical procedure from the data based upon, forexample, the particular combination(s) of received data or theparticular order in which the data is received from the data sources2426. The contextual information inferred from the received data caninclude, for example, the type of surgical procedure being performed,the particular step of the surgical procedure that the surgeon isperforming, the type of tissue being operated on, or the body cavitythat is the subject of the procedure. This ability by some aspects ofthe surgical hub 2404 to derive or infer information related to thesurgical procedure from received data can be referred to as “situationalawareness.” In one exemplification, the surgical hub 2404 canincorporate a situational awareness system, which is the hardware and/orprogramming associated with the surgical hub 2404 that derivescontextual information pertaining to the surgical procedure from thereceived data.

The situational awareness system of the surgical hub 2404 can beconfigured to derive the contextual information from the data receivedfrom the data sources 2426 in a variety of different ways. In oneexemplification, the situational awareness system includes a patternrecognition system, or machine learning system (e.g., an artificialneural network), that has been trained on training data to correlatevarious inputs (e.g., data from databases 2422, patient monitoringdevices 2424, and/or modular devices 2402) to corresponding contextualinformation regarding a surgical procedure. In other words, a machinelearning system can be trained to accurately derive contextualinformation regarding a surgical procedure from the provided inputs. Inanother exemplification, the situational awareness system can include alookup table storing pre-characterized contextual information regardinga surgical procedure in association with one or more inputs (or rangesof inputs) corresponding to the contextual information. In response to aquery with one or more inputs, the lookup table can return thecorresponding contextual information for the situational awarenesssystem for controlling the modular devices 2402. In one exemplification,the contextual information received by the situational awareness systemof the surgical hub 2404 is associated with a particular controladjustment or set of control adjustments for one or more modular devices2402. In another exemplification, the situational awareness systemincludes a further machine learning system, lookup table, or other suchsystem, which generates or retrieves one or more control adjustments forone or more modular devices 2402 when provided the contextualinformation as input.

A surgical hub 2404 incorporating a situational awareness systemprovides a number of benefits for the surgical system 2400. One benefitincludes improving the interpretation of sensed and collected data,which would in turn improve the processing accuracy and/or the usage ofthe data during the course of a surgical procedure. To return to aprevious example, a situationally aware surgical hub 2404 coulddetermine what type of tissue was being operated on; therefore, when anunexpectedly high force to close the surgical instrument's end effectoris detected, the situationally aware surgical hub 2404 could correctlyramp up or ramp down the motor of the surgical instrument for the typeof tissue.

As another example, the type of tissue being operated can affect theadjustments that are made to the compression rate and load thresholds ofa surgical stapling and cutting instrument for a particular tissue gapmeasurement. A situationally aware surgical hub 2404 could infer whethera surgical procedure being performed is a thoracic or an abdominalprocedure, allowing the surgical hub 2404 to determine whether thetissue clamped by an end effector of the surgical stapling and cuttinginstrument is lung (for a thoracic procedure) or stomach (for anabdominal procedure) tissue. The surgical hub 2404 could then adjust thecompression rate and load thresholds of the surgical stapling andcutting instrument appropriately for the type of tissue.

As yet another example, the type of body cavity being operated in duringan insufflation procedure can affect the function of a smoke evacuator.A situationally aware surgical hub 2404 could determine whether thesurgical site is under pressure (by determining that the surgicalprocedure is utilizing insufflation) and determine the procedure type.As a procedure type is generally performed in a specific body cavity,the surgical hub 2404 could then control the motor rate of the smokeevacuator appropriately for the body cavity being operated in. Thus, asituationally aware surgical hub 2404 could provide a consistent amountof smoke evacuation for both thoracic and abdominal procedures.

As yet another example, the type of procedure being performed can affectthe optimal energy level for an ultrasonic surgical instrument or radiofrequency (RF) electrosurgical instrument to operate at. Arthroscopicprocedures, for example, require higher energy levels because the endeffector of the ultrasonic surgical instrument or RF electrosurgicalinstrument is immersed in fluid. A situationally aware surgical hub 2404could determine whether the surgical procedure is an arthroscopicprocedure. The surgical hub 2404 could then adjust the RF power level orthe ultrasonic amplitude of the generator (i.e., “energy level”) tocompensate for the fluid filled environment. Relatedly, the type oftissue being operated on can affect the optimal energy level for anultrasonic surgical instrument or RF electrosurgical instrument tooperate at. A situationally aware surgical hub 2404 could determine whattype of surgical procedure is being performed and then customize theenergy level for the ultrasonic surgical instrument or RFelectrosurgical instrument, respectively, according to the expectedtissue profile for the surgical procedure. Furthermore, a situationallyaware surgical hub 2404 can be configured to adjust the energy level forthe ultrasonic surgical instrument or RF electrosurgical instrumentthroughout the course of a surgical procedure, rather than just on aprocedure-by-procedure basis. A situationally aware surgical hub 2404could determine what step of the surgical procedure is being performedor will subsequently be performed and then update the control algorithmsfor the generator and/or ultrasonic surgical instrument or RFelectrosurgical instrument to set the energy level at a valueappropriate for the expected tissue type according to the surgicalprocedure step.

As yet another example, data can be drawn from additional data sources2426 to improve the conclusions that the surgical hub 2404 draws fromone data source 2426. A situationally aware surgical hub 2404 couldaugment data that it receives from the modular devices 2402 withcontextual information that it has built up regarding the surgicalprocedure from other data sources 2426. For example, a situationallyaware surgical hub 2404 can be configured to determine whetherhemostasis has occurred (i.e., whether bleeding at a surgical site hasstopped) according to video or image data received from a medicalimaging device. However, in some cases the video or image data can beinconclusive. Therefore, in one exemplification, the surgical hub 2404can be further configured to compare a physiologic measurement (e.g.,blood pressure sensed by a BP monitor communicably connected to thesurgical hub 2404) with the visual or image data of hemostasis (e.g.,from a medical imaging device 124 (FIG. 2 ) communicably coupled to thesurgical hub 2404) to make a determination on the integrity of thestaple line or tissue weld. In other words, the situational awarenesssystem of the surgical hub 2404 can consider the physiologicalmeasurement data to provide additional context in analyzing thevisualization data. The additional context can be useful when thevisualization data may be inconclusive or incomplete on its own.

Another benefit includes proactively and automatically controlling thepaired modular devices 2402 according to the particular step of thesurgical procedure that is being performed to reduce the number of timesthat medical personnel are required to interact with or control thesurgical system 2400 during the course of a surgical procedure. Forexample, a situationally aware surgical hub 2404 could proactivelyactivate the generator to which an RF electrosurgical instrument isconnected if it determines that a subsequent step of the procedurerequires the use of the instrument. Proactively activating the energysource allows the instrument to be ready for use a soon as the precedingstep of the procedure is completed.

As another example, a situationally aware surgical hub 2404 coulddetermine whether the current or subsequent step of the surgicalprocedure requires a different view or degree of magnification on thedisplay according to the feature(s) at the surgical site that thesurgeon is expected to need to view. The surgical hub 2404 could thenproactively change the displayed view (supplied by, e.g., a medicalimaging device for the visualization system 108) accordingly so that thedisplay automatically adjusts throughout the surgical procedure.

As yet another example, a situationally aware surgical hub 2404 coulddetermine which step of the surgical procedure is being performed orwill subsequently be performed and whether particular data orcomparisons between data will be required for that step of the surgicalprocedure. The surgical hub 2404 can be configured to automatically callup data screens based upon the step of the surgical procedure beingperformed, without waiting for the surgeon to ask for the particularinformation.

Another benefit includes checking for errors during the setup of thesurgical procedure or during the course of the surgical procedure. Forexample, a situationally aware surgical hub 2404 could determine whetherthe operating theater is setup properly or optimally for the surgicalprocedure to be performed. The surgical hub 2404 can be configured todetermine the type of surgical procedure being performed, retrieve thecorresponding checklists, product location, or setup needs (e.g., from amemory), and then compare the current operating theater layout to thestandard layout for the type of surgical procedure that the surgical hub2404 determines is being performed. In one exemplification, the surgicalhub 2404 can be configured to compare the list of items for theprocedure scanned by a suitable scanner for example and/or a list ofdevices paired with the surgical hub 2404 to a recommended oranticipated manifest of items and/or devices for the given surgicalprocedure. If there are any discontinuities between the lists, thesurgical hub 2404 can be configured to provide an alert indicating thata particular modular device 2402, patient monitoring device 2424, and/orother surgical item is missing. In one exemplification, the surgical hub2404 can be configured to determine the relative distance or position ofthe modular devices 2402 and patient monitoring devices 2424 viaproximity sensors, for example. The surgical hub 2404 can compare therelative positions of the devices to a recommended or anticipated layoutfor the particular surgical procedure. If there are any discontinuitiesbetween the layouts, the surgical hub 2404 can be configured to providean alert indicating that the current layout for the surgical proceduredeviates from the recommended layout.

As another example, a situationally aware surgical hub 2404 coulddetermine whether the surgeon (or other medical personnel) was making anerror or otherwise deviating from the expected course of action duringthe course of a surgical procedure. For example, the surgical hub 2404can be configured to determine the type of surgical procedure beingperformed, retrieve the corresponding list of steps or order ofequipment usage (e.g., from a memory), and then compare the steps beingperformed or the equipment being used during the course of the surgicalprocedure to the expected steps or equipment for the type of surgicalprocedure that the surgical hub 2404 determined is being performed. Inone exemplification, the surgical hub 2404 can be configured to providean alert indicating that an unexpected action is being performed or anunexpected device is being utilized at the particular step in thesurgical procedure.

Overall, the situational awareness system for the surgical hub 2404improves surgical procedure outcomes by adjusting the surgicalinstruments (and other modular devices 2402) for the particular contextof each surgical procedure (such as adjusting to different tissue types)and validating actions during a surgical procedure. The situationalawareness system also improves surgeons' efficiency in performingsurgical procedures by automatically suggesting next steps, providingdata, and adjusting displays and other modular devices 2402 in thesurgical theater according to the specific context of the procedure.

Referring now to FIG. 21 , a timeline 2500 depicting situationalawareness of a hub, such as the surgical hub 106 or 206 (FIGS. 1-11 ),for example, is depicted. The timeline 2500 is an illustrative surgicalprocedure and the contextual information that the surgical hub 106, 206can derive from the data received from the data sources at each step inthe surgical procedure. The timeline 2500 depicts the typical steps thatwould be taken by the nurses, surgeons, and other medical personnelduring the course of a lung segmentectomy procedure, beginning withsetting up the operating theater and ending with transferring thepatient to a post-operative recovery room.

The situationally aware surgical hub 106, 206 receives data from thedata sources throughout the course of the surgical procedure, includingdata generated each time medical personnel utilize a modular device thatis paired with the surgical hub 106, 206. The surgical hub 106, 206 canreceive this data from the paired modular devices and other data sourcesand continually derive inferences (i.e., contextual information) aboutthe ongoing procedure as new data is received, such as which step of theprocedure is being performed at any given time. The situationalawareness system of the surgical hub 106, 206 is able to, for example,record data pertaining to the procedure for generating reports, verifythe steps being taken by the medical personnel, provide data or prompts(e.g., via a display screen) that may be pertinent for the particularprocedural step, adjust modular devices based on the context (e.g.,activate monitors, adjust the field of view (FOV) of the medical imagingdevice, or change the energy level of an ultrasonic surgical instrumentor RF electrosurgical instrument), and take any other such actiondescribed above.

As the first step 2502 in this illustrative procedure, the hospitalstaff members retrieve the patient's EMR from the hospital's EMRdatabase. Based on select patient data in the EMR, the surgical hub 106,206 determines that the procedure to be performed is a thoracicprocedure.

Second step 2504, the staff members scan the incoming medical suppliesfor the procedure. The surgical hub 106, 206 cross-references thescanned supplies with a list of supplies that are utilized in varioustypes of procedures and confirms that the mix of supplies corresponds toa thoracic procedure. Further, the surgical hub 106, 206 is also able todetermine that the procedure is not a wedge procedure (because theincoming supplies either lack certain supplies that are necessary for athoracic wedge procedure or do not otherwise correspond to a thoracicwedge procedure).

Third step 2506, the medical personnel scan the patient band via ascanner that is communicably connected to the surgical hub 106, 206. Thesurgical hub 106, 206 can then confirm the patient's identity based onthe scanned data.

Fourth step 2508, the medical staff turns on the auxiliary equipment.The auxiliary equipment being utilized can vary according to the type ofsurgical procedure and the techniques to be used by the surgeon, but inthis illustrative case they include a smoke evacuator, insufflator, andmedical imaging device. When activated, the auxiliary equipment that aremodular devices can automatically pair with the surgical hub 106, 206that is located within a particular vicinity of the modular devices aspart of their initialization process. The surgical hub 106, 206 can thenderive contextual information about the surgical procedure by detectingthe types of modular devices that pair with it during this pre-operativeor initialization phase. In this particular example, the surgical hub106, 206 determines that the surgical procedure is a VATS procedurebased on this particular combination of paired modular devices. Based onthe combination of the data from the patient's EMR, the list of medicalsupplies to be used in the procedure, and the type of modular devicesthat connect to the hub, the surgical hub 106, 206 can generally inferthe specific procedure that the surgical team will be performing. Oncethe surgical hub 106, 206 knows what specific procedure is beingperformed, the surgical hub 106, 206 can then retrieve the steps of thatprocedure from a memory or from the cloud and then cross-reference thedata it subsequently receives from the connected data sources (e.g.,modular devices and patient monitoring devices) to infer what step ofthe surgical procedure the surgical team is performing.

Fifth step 2510, the staff members attach the EKG electrodes and otherpatient monitoring devices to the patient. The EKG electrodes and otherpatient monitoring devices are able to pair with the surgical hub 106,206. As the surgical hub 106, 206 begins receiving data from the patientmonitoring devices, the surgical hub 106, 206 thus confirms that thepatient is in the operating theater.

Sixth step 2512, the medical personnel induce anesthesia in the patient.The surgical hub 106, 206 can infer that the patient is under anesthesiabased on data from the modular devices and/or patient monitoringdevices, including EKG data, blood pressure data, ventilator data, orcombinations thereof, for example. Upon completion of the sixth step2512, the pre-operative portion of the lung segmentectomy procedure iscompleted and the operative portion begins.

Seventh step 2514, the patient's lung that is being operated on iscollapsed (while ventilation is switched to the contralateral lung). Thesurgical hub 106, 206 can infer from the ventilator data that thepatient's lung has been collapsed, for example. The surgical hub 106,206 can infer that the operative portion of the procedure has commencedas it can compare the detection of the patient's lung collapsing to theexpected steps of the procedure (which can be accessed or retrievedpreviously) and thereby determine that collapsing the lung is the firstoperative step in this particular procedure.

Eighth step 2516, the medical imaging device (e.g., a scope) is insertedand video from the medical imaging device is initiated. The surgical hub106, 206 receives the medical imaging device data (i.e., video or imagedata) through its connection to the medical imaging device. Upon receiptof the medical imaging device data, the surgical hub 106, 206 candetermine that the laparoscopic portion of the surgical procedure hascommenced. Further, the surgical hub 106, 206 can determine that theparticular procedure being performed is a segmentectomy, as opposed to alobectomy (note that a wedge procedure has already been discounted bythe surgical hub 106, 206 based on data received at the second step 2504of the procedure). The data from the medical imaging device 124 (FIG. 2) can be utilized to determine contextual information regarding the typeof procedure being performed in a number of different ways, including bydetermining the angle at which the medical imaging device is orientedwith respect to the visualization of the patient's anatomy, monitoringthe number or medical imaging devices being utilized (i.e., that areactivated and paired with the surgical hub 106, 206), and monitoring thetypes of visualization devices utilized. For example, one technique forperforming a VATS lobectomy places the camera in the lower anteriorcorner of the patient's chest cavity above the diaphragm, whereas onetechnique for performing a VATS segmentectomy places the camera in ananterior intercostal position relative to the segmental fissure. Usingpattern recognition or machine learning techniques, for example, thesituational awareness system can be trained to recognize the positioningof the medical imaging device according to the visualization of thepatient's anatomy. As another example, one technique for performing aVATS lobectomy utilizes a single medical imaging device, whereas anothertechnique for performing a VATS segmentectomy utilizes multiple cameras.As yet another example, one technique for performing a VATSsegmentectomy utilizes an infrared light source (which can becommunicably coupled to the surgical hub as part of the visualizationsystem) to visualize the segmental fissure, which is not utilized in aVATS lobectomy. By tracking any or all of this data from the medicalimaging device, the surgical hub 106, 206 can thereby determine thespecific type of surgical procedure being performed and/or the techniquebeing used for a particular type of surgical procedure.

Ninth step 2518, the surgical team begins the dissection step of theprocedure. The surgical hub 106, 206 can infer that the surgeon is inthe process of dissecting to mobilize the patient's lung because itreceives data from the RF or ultrasonic generator indicating that anenergy instrument is being fired. The surgical hub 106, 206 cancross-reference the received data with the retrieved steps of thesurgical procedure to determine that an energy instrument being fired atthis point in the process (i.e., after the completion of the previouslydiscussed steps of the procedure) corresponds to the dissection step. Incertain instances, the energy instrument can be an energy tool mountedto a robotic arm of a robotic surgical system.

Tenth step 2520, the surgical team proceeds to the ligation step of theprocedure. The surgical hub 106, 206 can infer that the surgeon isligating arteries and veins because it receives data from the surgicalstapling and cutting instrument indicating that the instrument is beingfired. Similarly to the prior step, the surgical hub 106, 206 can derivethis inference by cross-referencing the receipt of data from thesurgical stapling and cutting instrument with the retrieved steps in theprocess. In certain instances, the surgical instrument can be a surgicaltool mounted to a robotic arm of a robotic surgical system.

Eleventh step 2522, the segmentectomy portion of the procedure isperformed. The surgical hub 106, 206 can infer that the surgeon istransecting the parenchyma based on data from the surgical stapling andcutting instrument, including data from its cartridge. The cartridgedata can correspond to the size or type of staple being fired by theinstrument, for example. As different types of staples are utilized fordifferent types of tissues, the cartridge data can thus indicate thetype of tissue being stapled and/or transected. In this case, the typeof staple being fired is utilized for parenchyma (or other similartissue types), which allows the surgical hub 106, 206 to infer that thesegmentectomy portion of the procedure is being performed.

Twelfth step 2524, the node dissection step is then performed. Thesurgical hub 106, 206 can infer that the surgical team is dissecting thenode and performing a leak test based on data received from thegenerator indicating that an RF or ultrasonic instrument is being fired.For this particular procedure, an RF or ultrasonic instrument beingutilized after parenchyma was transected corresponds to the nodedissection step, which allows the surgical hub 106, 206 to make thisinference. It should be noted that surgeons regularly switch back andforth between surgical stapling/cutting instruments and surgical energy(i.e., RF or ultrasonic) instruments depending upon the particular stepin the procedure because different instruments are better adapted forparticular tasks. Therefore, the particular sequence in which thestapling/cutting instruments and surgical energy instruments are usedcan indicate what step of the procedure the surgeon is performing.Moreover, in certain instances, robotic tools can be utilized for one ormore steps in a surgical procedure and/or handheld surgical instrumentscan be utilized for one or more steps in the surgical procedure. Thesurgeon(s) can alternate between robotic tools and handheld surgicalinstruments and/or can use the devices concurrently, for example. Uponcompletion of the twelfth step 2524, the incisions are closed up and thepost-operative portion of the procedure begins.

Thirteenth step 2526, the patient's anesthesia is reversed. The surgicalhub 106, 206 can infer that the patient is emerging from the anesthesiabased on the ventilator data (i.e., the patient's breathing rate beginsincreasing), for example.

Lastly, the fourteenth step 2528 is that the medical personnel removethe various patient monitoring devices from the patient. The surgicalhub 2106, 2236 can thus infer that the patient is being transferred to arecovery room when the hub loses EKG, BP, and other data from thepatient monitoring devices. As can be seen from the description of thisillustrative procedure, the surgical hub 2106, 2236 can determine orinfer when each step of a given surgical procedure is taking placeaccording to data received from the various data sources that arecommunicably coupled to the surgical hub 2106, 2236.

Situational awareness is further described in various U.S. PatentApplications that are incorporated by reference herein in the presentdisclosure, which is herein incorporated by reference in its entirety.In certain instances, operation of a robotic surgical system, includingthe various robotic surgical systems disclosed herein, for example, canbe controlled by the hub 2106, 2236 based on its situational awarenessand/or feedback from the components thereof and/or based on informationfrom the cloud 2104 (FIG. 17 ).

FIG. 22 is a logic flow diagram of a process 4000 depicting a controlprogram or a logic configuration for correlating visualization data withinstrument data, in accordance with at least one aspect of the presentdisclosure. The process 4000 is generally executed during a surgicalprocedure and includes: receiving or deriving 4001 a first data set,visualization data, from a surgical visualization system indicative of avisual aspect of the surgical instrument relative to a surgical field,receiving or deriving 4002 a second data set, instrument data, from thesurgical instrument indicative of a functional aspect of the surgicalinstrument, and correlating 4003 the first data set with the second dataset.

In at least one example, correlating the visualization data with theinstrument data is implemented by developing a composite data set fromthe visualization data and the instrument data. The process 4000 mayfurther include comparing the composite data set to another compositedata set, which can be received from an external source and/or can bederived from previously collected composite data sets. In at least oneexample, the process 4000 includes displaying a comparison of the twocomposite data sets, as described in greater detail below.

The visualization data of the process 4000 can be indicative of a visualaspect of the end effector of the surgical instrument relative to tissuein the surgical field. Additionally, or alternatively, the visualizationdata can be indicative of a visual aspect of the tissue being treated bythe end effector of the surgical instrument. In at least one example,the visualization data represents one or more positions of the endeffector, or a component thereof, relative to the tissue in the surgicalfield. Additionally, or alternatively, the visualization data mayrepresent one or more movements of the end effector, or a componentthereof, relative to the tissue in the surgical field. In at least oneexample, the visualization data represents one or more changes in shape,dimensions, and/or color of the tissue being treated by the end effectorof the surgical instrument.

In various aspects, the visualization data is derived from a surgicalvisualization system (e.g. visualization system 100, 160, 500, 2108).The visualization data can be derived from various measurements,readings, and/or any other suitable parameters monitored and/or capturedby a surgical visualization system, as described in greater detail inconnection with FIGS. 1-18 . In various examples, the visualization datais indicative of one or more visual aspects of tissue in a surgicalfield and/or one more visual aspects of a surgical instrument relativeto the tissue in the surgical field. In certain examples, thevisualization data represents or identifies position and/or movement ofan end effector of the surgical instrument relative to a criticalstructure (e.g. the critical structure 101 in FIG. 1 ) in the surgicalfield. In certain examples, the visualization data is derived fromsurface mapping data, imaging data, tissue identification data, and/ordistance data computed by surface mapping logic 136, imaging logic 138,tissue identification logic 140, or distance determining logic 141 orany combinations of the logic 136, 138, 140, and 141.

In at least one example, the visualization data is derived from tissueidentification and geometric surface mapping performed by thevisualization system 100 in combination with a distance sensor system104, as described in greater detail in connection with FIG. 1 . In atleast one example, the visualization data is derived from measurements,readings, or any other sensor data captured by the imaging device 120.As described in connection with FIG. 1 , the imaging device 120 is aspectral camera (e.g. a hyperspectral camera, multispectral camera, orselective spectral camera), which is configured to detect reflectedspectral waveforms and generate a spectral cube of images based on themolecular response to the different wavelengths.

Additionally, or alternatively, the visualization data can be derivedfrom measurements, readings, or any suitable sensor data captured by anysuitable imaging device that includes a camera or imaging sensor that isconfigured to detect visible light, spectral light waves (visible orinvisible), and a structured light pattern (visible or invisible), forexample. In at least one example, the visualization data is derived froma visualization system 160 that includes an optical waveform emitter 123and an waveform sensor 122 that is configured to detect the reflectedwaveforms, as described in greater detail in connection with FIGS. 3-4and 13-16 . In yet another example, the visualization data is derivedfrom a visualization system that includes a three-dimensional (3D)camera and associated electronic processing circuits such as, forexample, the visualization system 500. In yet another example, thevisualization data is derived from a structured (or patterned) lightsystem 700, which is described in greater detail in connection with FIG.12 . The foregoing examples can be used alone or in combination toderive the visualization data of the process 4000.

The instrument data of the process 4000 can be indicative of one or moreoperations of one or more internal components of the surgicalinstrument. In at least one example, the instrument data represents oneor more operational parameters of an internal component of the surgicalinstrument. The instrument data may represent one or more positionsand/or one or more movements of one or more internal components of thesurgical instrument. In at least one example, the internal component isa cutting member configured to cut the tissue during a firing sequenceof the surgical instrument. Additionally, or alternatively, the internalcomponent can include one or more staples configured to be fired intothe tissue during the firing sequence of the surgical instrument.

In at least one example, the instrument data represents one or moreoperations of one or more components of one or more drive assemblies ofthe surgical instrument such as, for example, an articulation driveassembly, a closure drive assembly, a rotation drive assembly, and/or afiring drive assembly. In at least one example, the instrument data setrepresents one or more operations of one or more drive members of thesurgical instrument such as, for example, an articulation drive member,a closure drive member, a rotation drive member, and/or a firing drivemember.

FIG. 23 is a schematic diagram of an example surgical instrument 4600for use with the process 4000 that is similar in many respects to othersurgical instruments or tools described by the present disclosure suchas, for example, the surgical instrument 2112. For brevity, variousaspects of the process 4000 are only described by the present disclosureusing a handheld surgical instrument. However, this is not limiting.Such aspects of the process 4000 can be equally implemented using arobotic surgical tool such as, for example, the surgical tool 2117.

The surgical instrument 4600 includes a plurality of motors, which canbe activated to perform various functions. The plurality of motors ofsurgical instrument 4600 can be activated to cause firing, closure,and/or articulation motions in the end effector. The firing, closure,and/or articulation motions can be transmitted to an end effector of thesurgical instrument 4600 through a shaft assembly, for example. In otherexamples, however, a surgical instrument for use with the process 4000can be configured to perform one or more of the firing, closure, andarticulation motions manually. In at least one example, the surgicalinstrument 4600 includes an end effector that treats tissue by deployingstaples into the tissue. In another example, the surgical instrument4600 includes an end effector that treats tissue by applying therapeuticenergy to the tissue.

In certain instances, the surgical instrument 4600 includes a firingmotor 4602. The firing motor 4602 may be operably coupled to a firingmotor drive assembly 4604, which can be configured to transmit firingmotions, generated by the firing motor 4602 to the end effector, inparticular to move a firing member in the form of an I-beam, forexample, which may include a cutting member. In certain instances, thefiring motions generated by the firing motor 4602 may cause the staplesto be deployed from a staple cartridge into tissue captured by the endeffector and, optionally, cause the cutting member of the I-beam to beadvanced to cut the captured tissue, for example.

In certain instances, the surgical instrument or tool may include aclosure motor 4603. The closure motor 4603 may be operably coupled to aclosure motor drive assembly 4605 which can be configured to transmitclosure motions, generated by the closure motor 4603 to the endeffector, in particular to displace a closure tube to close the anviland compress tissue between the anvil and the staple cartridge. Theclosure motions may cause the end effector to transition from an openconfiguration to an approximated configuration to capture tissue, forexample.

In certain instances, the surgical instrument or tool may include one ormore articulation motors 4606 a, 4606 b, for example. The articulationmotors 4606 a, 4606 b may be operably coupled to respective articulationmotor drive assemblies 4608 a, 4608 b, which can be configured totransmit articulation motions generated by the articulation motors 4606a, 4606 b to the end effector. In certain instances, the articulationmotions may cause the end effector to articulate relative to the shaft,for example.

In certain instances, the surgical instrument or tool may include acontrol module 4610 which can be employed with a plurality of motors ofthe surgical instrument 4600. Each of the motors 4602, 4603, 4606 a,4606 b may comprise a torque sensor to measure the output torque on theshaft of the motor. The force on an end effector may be sensed in anyconventional manner, such as by force sensors on the outer sides of thejaws or by a torque sensor for the motor actuating the jaws.

In various instances, as illustrated in FIG. 23 , the control module4610 may comprise a motor driver 4626 which may comprise one or moreH-Bridge FETs. The motor driver 4626 may modulate the power transmittedfrom a power source 4628 to a motor coupled to the control module 4610based on input from a microcontroller 4620 (the “controller”), forexample. In certain instances, the controller 4620 can be employed todetermine the current drawn by the motor, for example, while the motoris coupled to the control module 4610, as described above.

In certain instances, the controller 4620 may include a microprocessor4622 (the “processor”) and one or more non-transitory computer-readablemediums or memory units 4624 (the “memory”). In certain instances, thememory 4624 may store various program instructions, which when executedmay cause the processor 4622 to perform a plurality of functions and/orcalculations described herein. In certain instances, one or more of thememory units 4624 may be coupled to the processor 4622, for example. Invarious instances, the processor 4622 may control the motor driver 4626to control the position, direction of rotation, and/or velocity of amotor that is coupled to the control module 4610.

In certain instances, one or more mechanisms and/or sensors such as, forexample, sensors 4630 can be configured to detect forces (Force-to-Close“FTC”) applied by the jaws of an end effector of the surgical instrument4600 to tissue captured between the jaws. FTC can be transmitted to thejaws of the end effector through the closure motor drive assembly 4605.Additionally, or alternatively, the sensors 4630 can be configured todetect forces (Force-to-Fire “FTF”) applied to the end effector throughthe firing motor drive assembly 4604. In various examples, the sensors4630 can be configured to sense closure actuation (e.g., motor currentand FTC), firing actuation (e.g., motor current and FTF), articulation(e.g., the angular position of the end effector), and rotation of theshaft or the end effector.

One or more aspects of the process 4000 can be executed by one or moreof the control circuits (e.g. control circuit 132, 400, 410, 420, 602,622, 2108, 4620) described by the present disclosure. In at least oneexample, one or more aspects of the process 4000 are executed by acontrol circuit (e.g. control circuit 400 of FIG. 2A) that includes aprocessor and a memory storing a set of computer-executable instructionsthat, when executed by the processor, cause the processor to perform theone or more aspects of the process 4000. Additionally, or alternatively,one or more aspects of the process 4000 can be executed by acombinational logic circuit (e.g. control circuit 410 of FIG. 2B) and/ora sequential logic circuit (e.g. control circuit 420 of FIG. 2C).Furthermore, the process 4000 can be executed by any suitable circuitrywith any suitable hardware and/or software components that may belocated in or associated with various suitable systems described by thepresent disclosure.

In various aspects, the process 4000 can be implemented by acomputer-implemented interactive surgical system 2100 (FIG. 19 ) thatincludes one or more surgical systems 2102 and a cloud-based system(e.g., the cloud 2104 that may include a remote server 2113 coupled to astorage device 2105). Each surgical system 2102 includes at least onesurgical hub 2106 in communication with the cloud 2104 that may includea remote server 2113. The control circuit executing one or more aspectsof the process 4000 can be a component of a visualization system (e.g.visualization system 100, 160, 500, 2108), and can be in communicationwith a surgical instrument (e.g. surgical instrument 2112, 4600) toreceive the instrument data therefrom. The communication between thesurgical instrument and the control circuit of the visualization systemcan be a direct communication, or the instrument data can be routed tothe visualization system through a surgical hub 2106, for example. In atleast one example, the control circuit executing one or more aspects ofthe process 4000 can be a component of a surgical hub 2106.

Referring to FIG. 24 , in various examples, visualization data 4010 iscorrelated with instrument data 4011 by developing a composite data set4012 from the visualization data 4010 and the instrument data 4011. FIG.24 displays a current user's composite data set 4012 in a Graph 4013,which is developed from the current user's visualization data 4010 andthe current user's instrument data 4011. Graph 4013 illustratesvisualization data 4010 that represents a first usage cycle of asurgical instrument 4600, which involves jaw positioning, clamping, andfiring of the surgical instrument 4600. Graph 4013 also depictsvisualization data 4010 that represents the beginning of a second usagecycle of the surgical instrument 4600 where the jaws are repositionedfor a second clamping and firing of the surgical instrument 4600. Graph4013 further depicts the current user's instrument data 4011 in the formof FTC data 4014, correlated to clamping visualization data, and FTFdata 4015, correlated to firing visualization data.

As described above, the visualization data 4010 is derived from avisualization system (e.g. visualization system 100, 160, 500, 2108),and can represent, for example, the distance between the end effector ofthe surgical instrument 4600 and a critical structure in a surgicalfield during positioning, clamping, and/or firing of the end effector ofthe surgical instrument 4600. In at least one example, the visualizationsystem identifies the end effector, or components thereof, in thesurgical field, identifies a critical structure in the surgical field,and tracks the position of the end effector, or components thereof, withrespect to the critical structure or with respect to tissue around thecritical structure. In at least one example, the visualization systemidentifies jaws of the end effector in a surgical field, identifies acritical structure in the surgical field, and tracks the position of thejaws with respect to the critical structure or with respect to tissuearound the critical structure within the surgical.

In at least one example, the critical structure is a tumor. To removethe tumor, surgeons generally prefer to cut tissue along a safety marginaround the tumor to ensure that the entire tumor is removed. In suchexample, the visualization data 4010 can represent the distance betweenthe jaws of the end effector and the safety margin of the tumor duringpositioning, clamping, and/or firing of the surgical instrument 4600.

The process 4000 may further include comparing a current user'scomposite data set 4012 to another composite data set 4012′, which canbe received from an external source and/or can be derived frompreviously collected composite data sets. Graph 4013 illustrates acomparison between the current user's composite data set 4012 andanother composite data set 4012′ that includes visualization data 4010′and instrument data 4011′ including FTC data 4014′ and FTF data 4015′.The comparison can be presented to a user of the surgical instrument4600 in real time in the form of the graph 4013, or any other suitableformat. The control circuit executing one or more aspects of the process4000 may cause the comparison of two composite data sets to be displayedon any suitable screen within the operating room such as a screen of thevisualization system, for example. In at least one example, thecomparison can be displayed alongside the real-time video of thesurgical field captured on any suitable screen within the operatingroom. In at least one example, the control circuit is configured toadjust an instrument parameter to address a detected deviation betweenthe first composite data set and the second composite data set.

Furthermore, a control circuit (e.g. control circuit 132, 400, 410, 420,602, 622, 2108, 4620) executing one or more aspects of the process 4000may further cause current statuses of instrument data such as, forexample, FTF data and/or FTC data to be displayed against best practiceequivalents. In the example illustrated in FIG. 24 , a current value ofFTC—represented by a circle 4020—is depicted in real time against agauge 4021 with an indicator 4022 representing a best practice FTC.Likewise, a current value of FTF—represented by a circle 4023—isdepicted against a gauge 4024 with an indicator 4025 representing a bestpractice FTF. Such information can be overlaid onto the video feed ofthe surgical field in real time.

The example illustrated in FIG. 24 alerts the user that the current FTCis higher than the best practice FTC and that the current FTF is alsohigher than the best practice FTF. The control circuit executing one ormore aspects of the process 4000 may further alert the current user ofthe surgical instrument 4600—using an audible, visual, and/or hapticalerting mechanism—if the current value of the FTF and/or FTC reachesand/or moves beyond a predetermined threshold.

In certain instances, a control circuit (e.g. control circuit 132, 400,410, 420, 602, 622, 2108, 4620) executing one or more aspects of theprocess 4000 may further provide a current user of the surgicalinstrument 4600 with a projected instrument data based on currentinvestment data. For example, as illustrated in FIG. 24 , a projectedFTF 4015″ is determined based on a current value of the FTF, and isfurther displayed on the graph 4013 against current FTF 4015 andpreviously collected FTF′. Additionally, or alternatively, a projectedFTF circle 4026 can be displayed against the gauge 4024, as illustratedin FIG. 24 .

In various aspects, previously collected composite data sets and/or bestpractice FTF and/or FTC are determined from previous uses of thesurgical instrument 4600 in the same surgical procedure and/or othersurgical procedures performed by the user, other users within thehospitals, and/or users in other hospitals. Such data can be madeavailable to a control circuit (e.g. control circuit 132, 400, 410, 420,602, 622, 2108, 4620) executing one or more aspects of the process 4000by importation from a cloud 104, for example.

In various aspects, a control circuit (e.g. control circuit 132, 400,410, 420, 602, 622, 2108, 4620) executing one or more aspects of theprocess 4000 can cause feedback measurements of tissue thickness,compression, and stiffness to be visually overlaid onto a screen thatdisplays a live feed of the surgical instrument 4600 in the surgicalfield as the jaws of the end effector begin to deform the tissuecaptured therebetween during the clamping phase. The visual overlaycorrelates the visualization data representing tissue deformation tochanges in clamping force over time. The correlation helps a userconfirm proper cartridge selection, determine the time to start firing,as well as determine a suitable firing speed. The correlation canfurther inform an adaptive clamping algorithm. Adaptive firing speedchanges can be informed by measured forces as well as changes in tissuemotions immediately adjacent the jaws of the surgical instrument 4600(e.g. principal strains, tissue slippage, etc.) while a gauge or meterthat communicates the results is overlaid on the screen that displays alive feed of the end effector in the surgical field.

Further to the above, the kinematics of the surgical instrument 4600 canalso instruct instrument operation relative to another use or user. Thekinematics can be ascertained via accelerometers, torque sensors, forcesensors, motor encoders, or any other suitable sensors, and can yieldvarious force, velocity, and/or acceleration data of the surgicalinstrument, or components thereof, for correlation with correspondingvisualization data.

In various aspects, a control circuit (e.g. control circuit 132, 400,410, 420, 602, 622, 2108, 4620) executing one or more aspects of theprocess 4000 may cause an alternate surgical technique to be presented,if a deviation from the best-practice surgical technique is detectedfrom the visualization data and/or the instrument data. In at least oneexample, an adaptive display of instrument movement, force, tissueimpendence, and results from proposed alternative techniques arepresented. Where the visualization data indicates detection of a bloodvessel and a clip applier in the surgical field, a control circuit (e.g.control circuit 132, 400, 410, 420, 602, 622, 2108, 4620) executing oneor more aspects of the process 4000 may further ensure perpendicularityof the blood vessel with respect to the clip applier. The controlcircuit may suggest changing position, orientation, and/or roll angle toachieve the desired perpendicularity.

In various aspects, a control circuit (e.g. control circuit 132, 400,410, 420, 602, 622, 2108, 4620) may execute the process 4000 bycomparing real-time visualization data to pre-surgical planningsimulations. The user can utilize pre-operative patient scans tosimulate a surgical approach. The pre-surgical planning simulations canallow a user to follow a particular pre-surgical plan based on trainingruns. The control circuit can be configured to correlate fiduciallandmarks of the pre-operative scans/simulations with currentvisualization data. In at least one example, the control circuit mayemploy boundary tracking of an object to establish the correlation.

As a surgical instrument interacts with tissue and deforms surfacegeometry, the change in surface geometry as a function of the surgicalinstrument's position can be computed. For a given change in thesurgical instrument's position upon contact with the tissue, thecorresponding change in tissue geometry can depend on the sub-surfacestructures in the tissue region contacted by the surgical instrument.For example, in thoracic procedures, the change in tissue geometry inregions with airway substructures is different than regions withparenchyma substructures. Generally, stiffer substructures yield asmaller change in surface tissue geometry in response to a given changein the surgical instrument's position. In various aspects, a controlcircuit (e.g. control circuit 132, 400, 410, 420, 602, 622, 2108, 4620)can be configured to compute a running average of the change in thesurgical instrument position versus change in surface geometry for thegiven patient to give patient-specific differences. Additionally, oralternatively, the computed running average can be compared to a secondset of previously collected data. In certain instances, a surfacereference can be selected when no change in surface geometry is measuredper change in tool position. In at least one example, a control circuitcan be configured to determine the location of a substructure based ondetected surface geometry changes in response to a given contact betweena tissue region and a surgical instrument.

Furthermore, a control circuit (e.g. control circuit 132, 400, 410, 420,602, 622, 2108, 4620) can be configured to maintain a setinstrument-tissue contact throughout a tissue treatment based on thecorrelation between the set instrument-tissue contact and one or moretissue-surface geometry changes associated with the setinstrument-tissue contact. For example, the end effector of a surgicalinstrument 4600 may clamp tissue between its jaws at a desiredcompression setting the instrument-tissue contact. A correspondingchange in tissue-surface geometry can be detected by the visualizationsystem. Furthermore, a control circuit (e.g. control circuit 132, 400,410, 420, 602, 622, 2108, 4620) can derive visualization data indicativeof the change in tissue-surface geometry associated with the desiredcompression. The control circuit can further cause a motor setting ofthe closure motor 4603 (FIG. 22 ) to be automatically adjusted tomaintain the change in tissue-surface geometry associated with thedesired compression. This arrangement requires a continuous interactionbetween the surgical instrument 4600 and visualization system tomaintain the change in tissue-surface geometry associated with thedesired compression by continuously adjusting the jaw compressionagainst the tissue based on the visualization data.

In yet another example, where the surgical instrument 4600 is a robotictool attached to a robotic arm of a robotic surgical system (e.g.robotic system 110), the robotic surgical system can be configured toautomatically adjust one or more components of the robotic surgicalsystem to maintain a set surface contact with tissue based onvisualization data derived from a detected change in surface geometry ofthe tissue in response to the set surface contact with the tissue.

In various examples, the visualization data can be used in combinationwith measured instrument data to maintain contact between the tissueeither in position or load control allowing the user to manipulate thetissue to apply a predefined load to the tissue while moving theinstrument relative to the tissue. The user could specify that they wishto maintain contact or maintain a pressure and the visual tracking ofthe instrument along with the internal loading of the instrument couldbe used to enable repositioning without changing the fixed parameters.

Referring to FIGS. 25A and 25B, a screen 4601 of the visualizationsystem (e.g. visualization system 100, 160, 500, 2108) displays areal-time video feed of a surgical field during a surgical procedure. Anend effector 4642 of the surgical instrument 4600 includes jaws clampingtissue near a tumor identified in the surgical field via an overlaid MRIimage, for example. The jaws of the end effector 4642 comprise an anvil4643 and a channel housing a staple cartridge. At least one of the anvil4643 and the channel is movable relative to the other to capture tissuebetween the anvil 4643 and the staple cartridge. The captured tissue isthen stapled via staples 4644 deployable from the staple cartridgeduring a firing sequence of the surgical instrument 4600. In addition,the captured tissue is cut via a cutting member 4645 advanced distallyduring the firing sequence but slightly behind the staple deployment.

As apparent in FIG. 25A, during the firing sequence, the capturedtissue, and positions and/or movements of certain internal components ofthe end effector 4642 such as staples 4644 and cutting member 4645, maynot visible in a normal view 4640 of the live feed on the screen 4601.Certain end effectors include windows 4641, 4653 that permit a partialview of the cutting member 4645 in the beginning and the end of thefiring sequence but not during the firing sequence. Accordingly, a userof the surgical instrument 4600 is unable to track the firing sequenceprogress on the screen 4601.

FIG. 26 is a logic flow diagram of a process 4030 depicting a controlprogram or a logic configuration for synchronizing movement of a virtualrepresentation of an end-effector component with actual movement of theend-effector component, in accordance with at least one aspect of thepresent disclosure. The process 4030 is generally executed during asurgical procedure and includes detecting 4031 a movement of an internalcomponent of an end effector during the firing sequence, presenting, forexample by overlaying 4032, a virtual representation of the internalcomponent onto the end effector, and synchronizing 4033 a movement ofthe virtual representation on the screen 4601 with the detected movementof the internal component.

One or more aspects of the process 4030 can be executed by one or moreof the control circuits (e.g. control circuit 132, 400, 410, 420, 602,622, 2108, 4620) described by the present disclosure. In at least oneexample, one or more aspects of the process 4030 are executed by acontrol circuit (e.g. control circuit 400 of FIG. 2A) that includes aprocessor and a memory storing a set of computer-executable instructionsthat, when executed by the processor, cause the processor to perform theone or more aspects of the process 4030. Additionally, or alternatively,one or more aspects of the process 4030 can be executed by acombinational logic circuit (e.g. control circuit 410 of FIG. 2B) and/ora sequential logic circuit (e.g. control circuit 420 of FIG. 2C).Furthermore, the process 4030 can be executed by any suitable circuitrywith any suitable hardware and/or software components that may belocated in or associated with various suitable systems described by thepresent disclosure.

In various examples, a control circuit (e.g. control circuit 132, 400,410, 420, 602, 622, 2108, 4620) executing one or more aspects of theprocess 4030 may receive instrument data indicative of the movement ofan internal component of an end effector 4642 during a firing sequencethereof. The movement of the internal component can be tracked usingconventional rotary encoders of the firing motor 4602, for example. Inother examples, the movement of the internal component can be tracked bya tracking system that employs an absolute positioning system. Adetailed description of an absolute positioning system is described inU.S. Patent Application Publication No. 2017/0296213, titled SYSTEMS ANDMETHODS FOR CONTROLLING A SURGICAL STAPLING AND CUTTING INSTRUMENT,which published on Oct. 19, 2017, which is herein incorporated byreference in its entirety. In certain examples, the movement of theinternal component can be tracked using one or more position sensorsthat may comprise any number of magnetic sensing elements, such as, forexample, magnetic sensors classified according to whether they measurethe total magnetic field or the vector components of the magnetic field.

In various aspects, the process 4030 includes an overlay trigger. In atleast one example, the overlay trigger can be detecting that a tissue iscaptured by the end effector 4642. If tissue captured by the endeffector 4642 is detected, the process 4030 overlays, onto the endeffector 4642, a virtual representation of the cutting member 4645 at astarting position. The process 4030 further includes projecting staplelines, outlining where staples will be deployed into the capturedtissue. Furthermore, in response to an activation of the firing sequenceby the user, the process 4030 causes the virtual representation of thecutting member 4645 to move distally mimicking actual movement of thecutting member 4645 within the end effector 4642. As the staples aredeployed, the process 4030 converts unfired staples to fired staples,thereby allowing the user to visually track staple deployment andcutting member 4645 advancement in real-time.

In various examples, a control circuit (e.g. control circuit 132, 400,410, 420, 602, 622, 2108, 4620) executing one or more aspects of theprocess 4030 may detect that a tissue is captured by the end effector4642 from instrument data indicative of the force applied by the closuremotor 4603 (FIG. 22 ) to the jaws of the end effector 4642 through theclosure motor drive assembly 4605, for example. The control circuit mayfurther determine the position of the end effector within the surgicalfield from visualization data derived from a visualization system (e.g.visualization system 100, 160, 500, 2108). In at least one example, theend effector position can be determined with respect to a referencepoint in the tissue such as, for example, a critical structure.

In any event, the control circuit causes a virtual representation of theinternal component to be overlaid onto the end effector 4642 on thescreen 4601 at a position commensurate with the position of the internalcomponent within the end effector. The control circuit further causesthe projected virtual representation of the internal component to movesynchronously with the internal component during the firing sequence. Inat least one example, the synchronization is improved by the integrationof markings on the end effector 4642 that the control circuit can use asreference points for determining where to overlay the virtualrepresentation.

FIG. 25B illustrates an augmented view 4651 of the live feed of thesurgical field on the screen 4601. In the augmented view 4651 of theexample of FIG. 25B, virtual representations of the staples 4644 andcutting member 4645 are overlaid onto the end effector 4642 during thefiring sequence. The overlay distinguishes fired staples 4644 a fromunfired staples 4644 b, and distinguishes a completed cutline 4646 afrom a projected cutline 4646 b, which tracks the firing sequenceprogress. The overlay further shows the beginning of the staple lines4647, and a projected end 4649 of the staple lines in the cutline thatwill not reach the end of the tissue. Furthermore, based on the overlayof the tumor MRI image, a safe margin distance “d” between the tumor andthe projected cutline 4646 b is measured and presented with the overlay.The overlaid safe margin distance “d” assures the user that all of thetumor will be removed.

As illustrated in FIG. 25B, the control circuit is configured to causethe visualization system to continuously reposition the virtualrepresentation of the internal component to correlate with the actualmovement of the internal component. In the example of FIG. 25B, theoverlay shows the completed cutline 4646 a slightly lagging behind thefired staple lines 4644 a by a distance “d1”, which assures the userthat the firing sequence is progressing properly.

Referring now to FIG. 27 , a visualization system (e.g. visualizationsystem 100, 160, 500, 2108) can employ tool lighting 4058 and cameras4059 to detect and/or define trocar locations. Based on determinedtrocar locations, a user can be directed to the most suitable trocarport for completing an intended function based on time efficiency,location of a critical structure, and/or avoidance or risk.

FIG. 27 illustrates three trocar positions (Trocar 1, Trocar 2, Trocar3) extending through a body wall 4050 at different positions andorientations with respect to the body wall and with respect to acritical structure 4051 in a cavity 4052 inside the body wall 4050. Thetrocars are represented by arrows 4054, 4055, 4056. The lighting tool4058 could be used to detect trocar locations by using cascading lightor image on surrounding environment. Additionally, a light source of alighting tool 4058 could be a rotatable light source. In at least oneexample, the light source of the lighting tool 4058 and the camera 4059are utilized to detect distance of trocars relative to target locationsuch as, for example, the critical structure 4051. In various examples,the visualization system could suggest a location change of aninstrument if a more preferred instrument location is determined basedon the visualization data derived from the camera 4059 recording of thelight projected by the light source of the lighting tool 4058. A screen4060 can display the distance between a trocar and a target tissue,whether a tool access through the trocar is acceptable, risk associatedwith utilizing the trocar, and/or expected operating time using thetrocar, which can aid a user in selecting an optimal trocar forintroducing a surgical tool into the cavity 4052.

In various aspects, a surgical hub (e.g. surgical hub 2106, 2122) mayrecommend an optimal trocar for insertion of a surgical tool into thecavity 4052 based on user characteristics, which can be received from auser database, for example. The user characteristics include user handdominance, patient-side user preference, and/or user physicalcharacteristics (e.g. height, arm length, range of motion). The surgicalhub may utilize these characteristics, position and orientation data ofthe available trocars, and/or position data of a critical structure toselect an optimal trocar for insertion of a surgical tool in an effortto reduce user fatigue and increase efficiency. In various aspects, thesurgical hub may further cause a surgical instrument to invert itscontrols if the user inverts the end-effector orientation.

The surgical hub can reconfigure outputs of the surgical instrumentbased on visualization data. For example, the surgical hub may prohibitan activation of a therapeutic energy output of a surgical instrument ifthe visualization data indicates that the surgical instrument is beingretracted, or is being utilized to perform a different task.

In various aspects, the visualization system can be configured to trackblood surface or estimation of blood volume based reflective IR or redwavelength to delineate blood from non-blood surfaces and surfacegeometry measurements. This could be reported as an absolute staticmeasure or as a rate of change to provide quantitative data on amountand degree of change of bleeding.

Referring to FIG. 28 , various elements of a visualization system (e.g.visualization system 100, 160, 500, 2108) such as, for example, astructured light projector 706 and a camera 720 can be used to generatevisualization data of an anatomical organ to generate a virtual 3Dconstruct 4130 of the anatomical organ.

As described herein, structured light in the form of stripes or lines,for example, can be projected from a light source and/or projector 706onto the surface 705 of targeted anatomy to identify the shape andcontours of the surface 705. A camera 720, which can be similar invarious respects to the imaging device 120 (FIG. 1 ), for example, canbe configured to detect the projected pattern of light on the surface705. The way that the projected pattern deforms upon striking thesurface 705 allows vision systems to calculate the depth and surfaceinformation of the targeted anatomy.

FIG. 29 is a logic flow diagram of a process 4100 depicting a controlprogram or a logic configuration, in accordance with at least one aspectof the present disclosure. In various instances, the process 4100identifies 4101 a surgical procedure and identifies 4102 an anatomicalorgan targeted by the surgical procedure. The process 4100 furthergenerates 4104 a virtual 3D construct 4130 of at least a portion of theanatomical organ, identifies 4105 anatomical structures of at least aportion of the anatomical organ which are relevant to the surgicalprocedure, couples 4106 the anatomical structures to the virtual 3Dconstruct 4130, and overlays 4107 onto the virtual 3D construct 4130 alayout plan of the surgical procedure that is determined based on theanatomical structures.

One or more aspects of the process 4100 can be executed by one or moreof the control circuits (e.g. control circuit 132, 400, 410, 420, 602,622, 2108, 4620) described by the present disclosure. In at least oneexample, one or more aspects of the process 4100 are executed by acontrol circuit (e.g. control circuit 400 of FIG. 2A) that includes aprocessor and a memory storing a set of computer-executable instructionsthat, when executed by the processor, cause the processor to perform theone or more aspects of the process 4100. Additionally, or alternatively,one or more aspects of the process 4100 can be executed by acombinational logic circuit (e.g. control circuit 410 of FIG. 2B) and/ora sequential logic circuit (e.g. control circuit 420 of FIG. 2C).Furthermore, one or more aspects of the process 4100 can be executed byany suitable circuitry with any suitable hardware and/or softwarecomponents that may be located in or associated with various suitablesystems described by the present disclosure.

In various aspects, the process 4100 can be implemented by acomputer-implemented interactive surgical system 2100 (FIG. 19 ) thatincludes one or more surgical systems 2102 and a cloud-based system(e.g., the cloud 2104 that may include a remote server 2113 coupled to astorage device 2105). Each surgical system 2102 includes at least onesurgical hub 2106 in communication with the cloud 2104 that may includea remote server 2113. The control circuit executing one or more aspectsof the process 4100 can be a component of a visualization system (e.g.visualization system 100, 160, 500, 2108).

A control circuit (e.g. control circuit 132, 400, 410, 420, 602, 622,2108, 4620) executing one or more aspects of the process 4100 mayidentify 4101 a surgical procedure and/or identify 4102 an anatomicalorgan targeted by the surgical procedure by retrieving such informationfrom a database storing the information, or obtaining the informationdirectly from user input. In at least one example, the database isstored in a cloud-based system (e.g., the cloud 2104 that may include aremote server 2113 coupled to a storage device 2105). In at least oneexample, the database comprises hospital EMRs.

In one aspect, the surgical system 2200 comprises a surgical hub 2236connected to multiple operating theater devices such as, for example, avisualization system (e.g. visualization system 100, 160, 500, 2108)located in the operating theater. In at least one example, the surgicalhub 2236 comprises a communications interface for communicably couplingthe surgical hub 2236 to the visualization system, the cloud 2204,and/or the remote server 2213. A control circuit of the surgical hub2236 executing one or more aspects of the process 4100 may identify 4101a surgical procedure and/or identify 4102 an anatomical organ targetedby the surgical procedure by retrieving such information from a databasestored in the cloud 2204, and/or the remote server 2213.

The control circuit executing one or more aspects of the process 4100may cause a visualization system (e.g. visualization system 100, 160,500, 2108) to perform an initial scan of at least a portion of theanatomical organ to generate 4104 a three-dimensional (“3D”) construct4130 of at least a portion of the anatomical organ targeted by thesurgical procedure. In the example illustrated in FIG. 28 , theanatomical organ is a stomach 4110. The control circuit may cause one ormore elements of the visualization system such as, for example, astructured light projector 706 and a camera 720 utilize structured light4111 to generate visualization data by performing a scan of at least aportion of the anatomical organ when the camera(s) are introduced intothe body. The current visualization data, pre-operative data (e.g.patient scans and other relevant clinical data), visualization data fromprevious similar surgical procedures performed on the same or otherpatients, and/or user input can be leveraged to generate a 3D constructof at least a portion of the anatomical organ.

Furthermore, a control circuit executing one or more aspects of theprocess 4100 identifies 4105 anatomical structures of at least a portionof the anatomical organ, which are relevant to the surgical procedure.In at least one example, a user may select the anatomical structuresusing any suitable input device. Additionally, or alternatively, thevisualization system may include one or more imaging devices 120 withspectral cameras (e.g. a hyperspectral camera, multispectral camera, orselective spectral camera), which are configured to detect reflectedspectral waveforms and generate images based on the molecular responseto the different wavelengths. Optical absorption or refractiveproperties of the tissue can be utilized by the control circuit todistinguish different tissue types of the anatomical organ and, thereby,identify the relevant anatomical structures. In addition, currentvisualization data, pre-operative data (e.g. patient scans and otherrelevant clinical data), stored visualization data from previous similarsurgical procedures performed on the same or other patients, and/or userinput can be leveraged by the control circuit to identify the relevantanatomical structures.

The identified anatomical structures can be anatomical structures in asurgical field and/or anatomical structures are selected by a user. Invarious examples, position tracking of the relevant anatomicalstructures can be expanded beyond a current visibility view of a cameradirected at the surgical field. In one example, this is achieved byusing common visible coupled landmarks or through the use of secondarycoupled movement tracking. The secondary tracking could be accomplishedthrough a secondary imaging source, calculation of scope movement,and/or through pre-established beacons that are measures by a secondvisualization system, for example.

As described above in greater detail in connection with FIG. 14 , avisualization system can utilize a structured light projector 706 tocast an array of patterns or lines in which the camera 720 coulddetermine a distance to a target location. The visualization system canthen emit a known size pattern or line at a set distance equal to thedetermined distance. In addition, a spectral camera can determine a sizeof the pattern, which can vary depending on the optical absorption orrefractive properties of the tissue at the target location. Thedifference between the known size and the determined size is indicativeof tissue density at the target location, which is indicative of tissuetype at the target location. A control circuit executing one or moreaspects of the process 4100 may identify the relevant anatomicalstructures based, at least in part, on determined tissue densities attarget locations.

In at least one example, a detected abnormality in the tissue densitycan be associated with a disease state. Furthermore, the control circuitselect, update, or modify one or more settings of a surgical instrumenttreating the tissue based on the tissue density detected viavisualization data. For example, the control circuit may change variousclamping and/or firing parameters of a surgical stapler utilized tostaple and cut the tissue. In at least one example, the control circuitmay slow down the firing sequence and/or allow more clamping time basedon the tissue density detected by the visualization data. In variousexamples, the control circuit may alert a user of the surgicalinstrument to the abnormal tissue density by, for example, displayingover a screen, instructions to reduce bite size, increase or decreasethe energy delivery output for an electrosurgical instrument, and adjustthe amount the jaw closure. In another example, if the visualizationdata indicate that the tissue is a fatty tissue, the instructions couldbe to increase power to reduce energy application time.

Furthermore, identification of the surgical procedure type canfacilitate target organ identification by the control circuit. Forexample, if the procedure is a left upper lobectomy, it is highly likelythat the lung is the target organ. Accordingly, the control circuit willonly consider visualization data and non-visualization data relevant tothe lung and/or tools that are generally used in such procedure. Inaddition, knowledge of the procedure type better enables other imagefusion algorithms that inform tumor location and staple line placement,for example.

In various aspects, knowledge of surgical table position and/orinsufflation pressure can be used by a control circuit executing one ormore aspects of the process 4100 to establish a baseline position of atarget anatomical organ and/or relevant anatomical structures identifiedfrom visualization data. Motion of the surgical table (e.g., moving thepatient from a flat position to a reverse Trendelenburg position) cancause deformation of anatomical structures, which can be tracked, andcompared to a baseline, to continuously inform target organ and/orrelevant anatomical structures locations and states. Likewise, changesin insufflation pressure within a body cavity can interfere withbaseline visualization data of a target organ and/or relevant anatomicalstructures within the body cavity.

A control circuit (e.g. control circuit 132, 400, 410, 420, 602, 622,2108, 4620) may execute one or more aspects of a process that derivesbaseline visualization data of a target organ and/or relevant anatomicalstructures of a patient on a surgical table during a surgical procedure,determines a change in the surgical table position, and re-derives thebaseline visualization data of the target organ and/or the relevantanatomical structures of the patient in the new position.

Likewise, a control circuit (e.g. control circuit 132, 400, 410, 420,602, 622, 2108, 4620) may execute one or more aspects of a process thatderives baseline visualization data of a target organ and/or relevantanatomical structures of a patient on a surgical table during a surgicalprocedure, determines a change in insufflation pressure in the patient'sbody cavity, and re-derives the baseline visualization data of thetarget organ and/or the relevant anatomical structures of the patientunder the new insufflation pressure.

In various instances, the control circuit executing one or more aspectsof the process 4100 may couple identified anatomical structures to thevirtual 3D construct by overlaying landmarks or signs onto the virtual3D construct of the organ to indicate positions of the anatomicalstructures, as illustrated in FIG. 28 . The control circuit may alsocause user defined structures and tissue planes to be overlaid onto thevirtual 3D construct. In various aspects, a hierarchy of tissue typescan be established to organize the anatomical structures identified onthe virtual 3D construct. Table 1, which is provided below, sets forthexample hierarchies for the lung and the stomach.

ORGAN TIER 1 TIER 2 TIER 3 Lung Left Lung Left upper lobe Segments inthe left upper lobe, major vessels/airways Stomach Stomach Fundus,antrum, Angle of His, pylorus Angularis Incisura, Greater/LesserCurvature

In various aspects, relevant anatomical structures that are identifiedon a virtual 3D construct can be renamed and/or repositioned by a userto correct errors or for preference. In at least one example,corrections can be voice activated. In at least one example, correctionsare recorded for future machine learning.

Further to the above, a control circuit (e.g. control circuit 132, 400,410, 420, 602, 622, 2108, 4620) executing one or more aspects of theprocess 4100 may overlay 4107 a surgical procedure layout plan (e.g.layout plan 4120) onto the virtual 3D construct of the target organ(e.g. stomach 4110). In at least one example, the virtual 3D constructis displayed on a separate screen of the visualization system from thescreen displaying the live feed/view of the surgical field. In anotherexample, one screen may alternate displaying the live feed of thesurgical field and the 3D construct. In such example, a user can use anysuitable input device to alternate between the two views.

In the example illustrated in FIG. 28 , the control circuit hasdetermined that the surgical procedure is a sleeve gastrectomyprocedure, and that the target organ is the stomach. In an initial scanof the abdominal cavity, the control circuit identifies the stomach,liver, spleen, greater curvature of the stomach, and pylorus usingvisualization data such as, for example, structured light data and/orspectral data. This is informed by knowledge of the procedure and thestructures of interest.

Visualization data such as, for example, structured light data and/orspectral data can be utilized by the control circuit to identify thestomach 4110, liver, and/or the spleen by comparing current structuredlight data with stored structured light data previously associated withsuch organs. In at least one example, a control circuit (e.g. controlcircuit 132, 400, 410, 420, 602, 622, 2108, 4620) can utilize structuredlight data that represent signature anatomical contours of an organand/or spectral data that represent signature sub-surface tissuecharacteristics to identify anatomical structures relevant to a surgicalprocedure layout plan (e.g. layout plan 4120).

In at least one example, visualization data could be utilized toidentify the pyloric vein 4112, which indicates the position 4113 of thepylorus 4131, identify the gastric-omental vessel 4114, which indicatesthe position 4115 of the greater curvature of the stomach 4110, identifythe bend 4116 in the right gastric vein, which indicates the position4117 of the angle of incisura 4132, and/or identify a position 4119 ofthe Angle of His 4121. The control circuit may assign landmarks to oneor more of the identified position. In at least one example, asillustrated in FIG. 28 the control circuit causes the visualizationsystem to overlay landmarks onto the positions 4113, 4117, 4119 on avirtual 3D construct of stomach 4110 generated using visualization data,as described above. In various aspects, the landmarks can besynchronously overlaid onto the virtual 3D construct and the surgicalfield views to allow the user to switch between the views without losingsight of the landmarks. The user may zoom out in the view of the screendisplaying the virtual 3D construct to show the overall layout plan ormay zoom in to show a portion analogous to the surgical field view. Thecontrol circuit may continuously track and update the landmarks.

In a sleeve gastrectomy, the surgeon typically staples stomach tissueat, or about, 4 cm from the pylorus. Prior to stapling, an energy deviceis introduced into the abdominal cavity of the patient in the beginningof the sleeve gastrectomy procedure to dissect the gastroepiploic arteryand omentum away from the greater curvature at, or about, 4 cm from thepylorus. A control circuit that has identified the position 4113, asdescribed above, may automatically cause an overlay of an end effectorof the energy device at, or about, 4 cm from the position 4113. Theoverlay of the end effector of the energy device, or any suitablelandmark, at, or about, 4 cm from the pylorus identifies a startingposition of the sleeve gastrectomy.

As the surgeon dissects along the greater curvature of the stomach, thecontrol circuit causes the landmark at position 4113 and/or the overlaidend effector of the energy device to be removed. As the surgeonapproaches the spleen, a distance indicator is automatically overlaidonto the virtual 3D construct view and/or the surgical field view. Thecontrol circuit may cause the distance indicator to identify a 2 cmdistance from the spleen. The control circuit may cause the distanceindicator to flash and/or change colors when the dissection pathreaches, or is about to reach, 2 cm from the spleen, for example. Thedistance indicator overlay remains until the user reaches to theposition 4119 at the Angle of His 4121.

Referring to FIG. 30 , once a surgical stapler is introduced into theabdominal cavity, the control circuit may utilize visualization data toidentify the pylorus 4131, Angular Incisura 4132, greater curvature 4133of the stomach 4110, lesser curvature 4134 of the stomach 4110, and/orother anatomical structure relevant to the sleeve gastrectomy procedure.An overlay of a bougie can be shown as well. Introduction of a surgicalinstrument into a body cavity (e.g. introduction of the surgical staplerinto the abdominal cavity), can be detected by a control circuit fromvisualization data indicative of visual cues on the end effector, suchas distinctive colors, signs, and/or shapes. The control circuit canidentify the surgical instrument in a database storing such visual cuesand corresponding visual cues. Alternatively, the control circuit mayprompt a user to identify the surgical instrument inserted into the bodycavity. Alternatively, a surgical trocar facilitating access to the bodycavity may include one or more sensors for detecting a surgicalinstrument inserted therethrough. In at least one example, the sensorscomprise an RFID reader configured to identify the surgical instrumentfrom an RFID chip on the surgical instrument.

In addition to the landmarks identifying relevant anatomical structures,the visualization system may also overlay a procedure layout plan 4135,which can be in the form a recommended treatment path, onto the 3Dcritical structure and/or onto the surgical field view. In the exampleof FIG. 30 , the surgical procedure is a sleeve gastrectomy, and theprocedure layout plan 4135 is in the form of three resection paths 4136,4137, 4138 and corresponding outcome volumes of the resulting sleeves.

As illustrated in FIG. 30 , distances (a, a₁, a₂) from the pylorus 4131to starting points for making the sleeves. Each starting point yields adifferent sleeve size (e.g. 400 cc, 425 cc, 450 cc for the startingpoints 4146, 4147, 4148, at distances a, a₁, a₂ from pylorus 4131,respectively). In one example, the control circuit prompts the user toenter a size selection and, in response, present a procedure layoutplan, which can be in the form of a resection path, which yields theselected sleeve size. In another example, as illustrated in FIG. 30 ,the control circuit presents a plurality of resection paths 4136, 4137,4138 and corresponding sleeve sizes. The user may then select one of theproposed resection paths 4136, 4137, 4138 and, in response, the controlcircuit removes the unselected resection paths.

In yet another example, the control circuit allows the user to makeadjustments to a proposed resection path on a screen showing theresection path overlaid onto the virtual 3D construct and/or thesurgical field. The control circuit may calculate a sleeve size based onthe adjustments. Alternatively, in another example, the user ispermitted to select a starting point, for forming the sleeve, at adesired distance from the pylorus 4131. In response, the control circuitcalculates a sleeve size based on the selected starting point.

Presenting resection paths can be achieved by causing the visualizationsystem to overlay the resection paths onto the virtual 3D construct viewand/or the surgical field view, for example. Conversely, removingproposed resection paths can be achieved by causing the visualizationsystem to remove the overlay of such resection paths from the virtual 3Dconstruct view and/or the surgical field view.

Referring still to FIG. 30 , in certain examples, once an end effectorof a surgical stapler clamps the stomach tissue between a startingpoint, selected from proposed starting points 4146, 4147, 4147, and anend position 4140, at a predefined distance from the Angle of incisura4132, the control circuit presents information about the clamping and/orfiring the surgical stapler. In at least one example, as illustrated inFIG. 24 , a composite data set 4012 from the visualization data 4010 andthe instrument data 4011 can be displayed. Additionally, oralternatively, FTC and/or FTF values can be displayed. For example, acurrent value of FTC—represented by a circle 4020—can be depicted inreal time against a gauge 4021 with an indicator 4022 representing abest practice FTC. Likewise, a current value of FTF—represented by acircle 4023—can be depicted against a gauge 4024 with an indicator 4025representing a best practice FTF.

After the surgical stapler is fired, recommendations for new cartridgeselections can be presented onto the screen of the surgical stapler orany of the screens of the visualization system, as described below ingreater detail. When the surgical stapler is removed from the abdominalcavity, reloaded with a selected staple cartridge, and reintroduced intothe abdominal cavity, distance indicators—identifying a constantdistance (d) from a plurality of points along the lesser curvature 4134of the stomach 4110 to the selected resection path—are overlaid onto thevirtual 3D construct view and/or the surgical field view. To ensure aproper orientation of the end effector of the surgical stapler, thedistance from the target of the distal end of the end effector of thesurgical stapler, as well as the distance from the proximal end to thepreviously fired staple lines are overlaid onto the virtual 3D constructview and/or the surgical field view. This process is repeated until theresection is complete.

One or more of the distances proposed and/or calculated by the controlcircuit can be determined based on stored data. In at least one example,the stored data includes preoperative data, user preference data, and/ordata from previously performed surgical procedures by the user or otherusers.

Referring to FIG. 31 , a process 4150 depicting a control program or alogic configuration for proposing resection paths for removing a portionof an anatomical organ, in accordance with at least one aspect of thepresent disclosure. The process 4150 identifies 4151 an anatomical organtargeted by the surgical procedure, identifies 4152 anatomicalstructures of the anatomical organ which are relevant to the surgicalprocedure, and proposes 4153 surgical resection paths for removing aportion of the anatomical organ by the surgical instrument, as describedin greater detail elsewhere herein in connection with the process 4100.The surgical resection paths are determined based on the anatomicalstructures. In at least one example, the surgical resection pathcomprise different starting points.

One or more aspects of the process 4150 can be executed by one or moreof the control circuits (e.g. control circuit 132, 400, 410, 420, 602,622, 2108, 4620) described by the present disclosure. In at least oneexample, one or more aspects of the process 4150 are executed by acontrol circuit (e.g. control circuit 400 of FIG. 2A) that includes aprocessor and a memory storing a set of computer-executable instructionsthat, when executed by the processor, cause the processor to perform theone or more aspects of the process 4150. Additionally, or alternatively,one or more aspects of the process 4150 can be executed by acombinational logic circuit (e.g. control circuit 410 of FIG. 2B) and/ora sequential logic circuit (e.g. control circuit 420 of FIG. 2C).Furthermore, the process 4150 can be executed by any suitable circuitrywith any suitable hardware and/or software components that may belocated in or associated with various suitable systems described by thepresent disclosure.

Referring to FIGS. 32A-32D, a control circuit (e.g. control circuit 132,400, 410, 420, 602, 622, 2108, 4620) executing on or more aspects of theprocess 4100 or the process 4150 may utilize dynamic visualization datato update or modify a surgical procedure layout plan in real time duringimplementation. In at least one example, the control circuit modifies aset resection path (FIG. 32B) for removing a portion of an organ or anabnormality (e.g. a tumor or region) by a surgical instrument to analternative resection path (FIG. 32D) based on the dynamic visualizationdata from one or more imaging devices of a visualization system (e.g.visualization system 100, 160, 500, 2108) tracking progress of thetissue being resected and surrounding tissue. The resection pathmodification can be triggered by a shift in the position of a criticalstructure (e.g. a blood vessel) into the resection path. For instance,the tissue resection process can sometimes lead to tissue inflammationthat changes the tissue shape and/or volume, which can cause a criticalstructure (e.g. a blood vessel) to shift position. Dynamic visualizationdata enable the control circuit to detect position and/or volume changesof critical structures and/or relevant anatomical structure near a setresection path. If the changes in position and/or volume cause thecritical structures to shift into, or within a safe margin from, theresection path, the control circuit modifies the set resection path byselecting, or at least recommending, an alternative resection path ofthe surgical instrument.

FIG. 32A illustrates a live view 4201 of a surgical field on a screen4230 of the visualization system. A surgical instrument 4200 isintroduced into the surgical field to remove a target region 4203. Aninitial plan layout 4209 for removing the region is overlaid onto thelive view 4201, as illustrated in the expanded view of the region 4203in FIG. 32B. The region 4203 is surrounded by critical structures 4205,4206, 4207, 4208. The initial plan layout 4209, as illustrated in FIG.32B, extends a resection path around the region 4203 at a predefinedsafe margin from the region 4203. The resection path avoids crossingover or passing through a critical structure by extending either on theoutside (e.g. critical structure 4208) or on the inside (e.g. criticalstructure 4206) of the critical structure. As described above, theinitial plan layout 4209 is determined by the control circuit based onvisualization data from visualization system.

FIG. 32C illustrates a live view 4201′ of the surgical field on thescreen 4230 of the visualization system at a later time (00:43). An endeffector 4202 of the surgical instrument 4200 resects tissue along thepredefined resection path defined by the layout plan 4209. A volumechange of tissue including the region 4203 due tissue inflammation, forexample, causes critical structures 4206 and 4208 to be shifted into thepredefined resection path. In response, the control circuit proposes analternative resection path 4210 that navigates around the criticalstructures 4206, 4208, which protects the critical structures 4206, 4208from being damaged, as illustrated in FIG. 32D. In various examples,alternative resection paths can be proposed to optimize the amount ofhealthy tissue that would remain and provide user with guidance toensure they did not hit critical structures which would minimizebleeding and, therefore, reducing surgery time and pressure of dealingwith unintended situations, while balancing that against the impacts onremaining organ volume.

In various aspects, a control circuit executing one or more aspects ofone or more of the processes described by the present disclosure mayreceive and/or derive visualization data from multiple imaging devicesof a visualization system. The visualization data facilitates trackingof critical structures that are outside the live view of the surgicalfield. Common landmarks can allow the control circuit to consolidate thevisualization data from multiple imaging devices of the visualizationsystem. In at least one example, secondary tracking of criticalstructures outside a live view of the surgical filed, for example, couldbe achieved through a secondary imaging source, calculation of scopemovement, or through pre-established beacons/landmarks that are measureby a second system.

Referring generally to FIGS. 33-35 , a logic flow diagram of a process4300 depicts a control program or a logic configuration for presenting,or overlaying, parameters of a surgical instrument onto, or near, aproposed surgical resection path, in accordance with at least one aspectof the present disclosure. The process 4300 is generally executed duringa surgical procedure and includes identifying 4301 an anatomical organtargeted by the surgical procedure, identifying 4302 anatomicalstructures relevant to the surgical procedure from visualization datafrom at least one imaging device, and proposing 4303 a surgicalresection path for removing a portion of the anatomical organ by asurgical instrument. In at least one example, the surgical resectionpath is determined based on the anatomical structures. The process 4300further includes presenting 4304 parameters of the surgical instrumentin accordance with the surgical resection path. Additionally, oralternatively, the process 4300 further includes adjusting 4305parameters of the surgical instrument in accordance with the surgicalresection path.

One or more aspects of the process 4300 can be executed by one or moreof the control circuits (e.g. control circuit 132, 400, 410, 420, 602,622, 2108, 4620) described by the present disclosure. In at least oneexample, one or more aspects of the process 4300 are executed by acontrol circuit (e.g. control circuit 400 of FIG. 2A) that includes aprocessor and a memory storing a set of computer-executable instructionsthat, when executed by the processor, cause the processor to perform theone or more aspects of the process 4030. Additionally, or alternatively,one or more aspects of the process 4300 can be executed by acombinational logic circuit (e.g. control circuit 410 of FIG. 2B) and/ora sequential logic circuit (e.g. control circuit 420 of FIG. 2C).Furthermore, the process 4300 can be executed by any suitable circuitrywith any suitable hardware and/or software components that may belocated in or associated with various suitable systems described by thepresent disclosure.

In various examples, a control circuit (e.g. control circuit 132, 400,410, 420, 602, 622, 2108, 4620) executing one or more aspects of theprocess 4300 may identify 4301 an anatomical organ targeted by thesurgical procedure, identify 4302 anatomical structures relevant to thesurgical procedure from visualization data from at least one imagingdevice of a visualization system (e.g. visualization system 100, 160,500, 2108), and/or propose 4303 a surgical resection path for removing aportion of the anatomical organ by a surgical instrument (e.g. surgicalinstrument 4600), as described elsewhere herein in connection with theprocesses 4150 (FIG. 31 ), 4100 (FIG. 29 ). Furthermore, the controlcircuit executing one or more aspects of the process 4300 may propose orrecommend one or more parameters of the surgical instrument inaccordance with the proposed 4303 surgical resection path. In at leastone example, the control circuit presents 4304 the recommendedparameters of the surgical instrument by overlaying such parametersonto, or near, the proposed surgical path, as illustrated in FIGS. 34and 35 .

FIG. 34 illustrates a virtual 3D construct 4130 of a stomach of apatient undergoing a sleeve gastrectomy performed using a surgicalinstrument 4600, in accordance with at least one aspect of the presentdisclosure. As described in greater detail in connection with FIG. 28 ,for example, various elements of a visualization system (e.g.visualization system 100, 160, 500, 2108) such as, for example, astructured light projector 706 and a camera 720 can be used to generatevisualization data to create the virtual 3D construct 4130. Relevantanatomical structures (e.g. pylorus 4131, Angular Incisura 4132, Angleof His 4121) are identified from visualization data from one or moreimaging devices of the visualization system. In at least one example,landmarks are assigned to positions 4113, 4117, 4119 of such anatomicalstructures by overlaying the landmarks onto the virtual 3D construct4130.

In addition, a surgical resection path 4312 is proposed 4303 based onthe identified anatomical structures. In at least one example, thecontrol circuit overlays the surgical resection path 4312 onto thevirtual 3D construct 4130, as illustrated in FIG. 34 . As described ingreater detail elsewhere herein, adjustments can be automatically madeto proposed surgical paths based on desired volume outputs. In addition,adjustments can be automatically made to projected margins based oncritical structures and/or tissue abnormalities automatically identifiedby the control circuit from the visualization data.

In various aspects, the control circuit executing at least one aspect ofthe process 4300 presents parameters 4314 of the surgical instrumentthat are selected in accordance with the proposed 4303 surgicalresection path 4312. In the example illustrated in FIG. 34 , theparameters 4314 are indicative of staple cartridges automaticallyselected for use with the surgical instrument 4600 in performing thesleeve gastrectomy based on the proposed 4303 surgical resection path.In at least one example, the parameters 4314 comprise at least one of astaple cartridge size, a staple cartridge color, a staple cartridgetype, and a staple cartridge length. In at least one example, thecontrol circuit presents 4304 the parameters 4314 of the surgicalinstrument 4600 by overlaying such parameters onto, or near, theproposed 4303 surgical resection path 4312, as illustrated in FIGS. 34and 35 .

In various aspects, the control circuit executing at least one aspect ofthe process 4300 presents tissue parameters 4315 along one or moreportions of the surgical resection path 4312. In the example illustratedin FIG. 34 , the tissue parameters 4315 are tissue thicknesses presentedby displaying a cross-section taken along the line A-A, which representstissue thicknesses along at least a portion of the surgical resectionpath 4312. In various aspects, the staple cartridges utilized by thesurgical instrument 4600 can be selected in accordance with the tissueparameters 4315. For example, as illustrated in FIG. 34 , a blackcartridge, which comprises a larger staple size, is selected for usewith the thicker muscle tissue of the Antrum, and a green cartridge,which comprises a smaller staple size, is selected for use with theheart muscle tissue of the body and fundus portions of the stomach.

The tissue parameters 4315 include at least one of a tissue thickness, atissue type, and a volume outcome of the sleeve resulting from theproposed surgical resection path 4312. Tissue parameters 4315 can bederived from previously captured CT, ultrasound, and/or MRI images ofthe organ of the patient and/or from previously known average tissuethicknesses. In at least one example, the surgical instrument 4600 is anintelligent instrument (similar to the intelligent instrument 2112), andthe tissue thicknesses and/or the selected staple cartridge informationare transmitted to the surgical instrument 4600 for optimization ofclosure setting, firing settings, and/or any other suitable surgicalinstrument settings. In one example, the tissue thickness and/or theselected staple cartridge information can be transmitted to the surgicalinstrument 4600 from a surgical hub (e.g. surgical hub 2106, 2122) incommunication with a visualization system (e.g. visualization system100, 160, 500, 2108) and the surgical instrument 4600, as described inconnection with FIGS. 17-19 .

In various examples, the control circuit executing at least one aspectof the process 4300 proposes an arrangement 4317 of two or more staplecartridge sizes (e.g. 45 mm and 60 mm) in accordance with determinedtissue thicknesses along at least a portion of the surgical resectionpath 4312. Furthermore, as illustrated in FIG. 35 , the control circuitmay further present the arrangement 4317 along the proposed 4303surgical resection path 4312. Alternatively, the control circuit canpresent a suitable arrangement 4317 along a user-selected surgicalresection path. The control circuit can determine tissue thicknessesalong the user-selected resection path, as described above, and proposea staple cartridge arrangement in accordance with the tissuethicknesses.

In various aspects, the control circuit executing one or more aspects ofthe process 4300 may propose a surgical resection path, or optimize aselected surgical resection path, to minimize the number of staplecartridges in the staple cartridge arrangement 4317 without compromisingthe size of the resulting sleeve beyond a predetermined threshold.Reducing the number of spent cartridges reduces procedure time and cost,and reduces patient trauma.

Still referring to FIG. 35 , the arrangement 4317 comprises a firststaple cartridge 4352 and a last staple cartridge 4353 defining thebeginning and end of the surgical resection path 4312. Where only asmall portion of a last staple cartridge 4353 of a proposed staplecartridge arrangement 4317 is needed, the control circuit may adjust thesurgical resection path 4312 to eliminate the need for the last staplecartridge 4353 without compromising the size of the resulting sleevebeyond a predetermined threshold.

In various examples, the control circuit executing at least one aspectof the process 4300 presents a virtual firing of the proposed staplecartridge arrangement 4317, which virtually separates the virtual 3Dconstruct 4130 into a retained portion 4318 and a removed portion 4319,as illustrated in FIG. 35 . The retained portion 4318 is a virtualrepresentation of a sleeve that would result from implementation of theproposed surgical resection path 4312 by firing the staple cartridgearrangement 4317. The control circuit may further determine an estimatevolume of the retained portion 4318 and/or the removed portion 4319. Thevolume of the retained portion 4318 represents the volume of theresulting sleeve. In at least one example, the volume of the retainedportion 4318 and/or the removed portion 4319 is derived from thevisualization data. In another example, the volume of the retainedportion 4318 and/or the removed portion 4319 is determined from adatabase storing retained volumes, removed portion volumes, andcorresponding surgical resection paths. The database can be constructedfrom surgical procedures previously performed on organs with the same,or at least similar, dimensions, which have been resected using thesame, or at least similar, resection paths.

In various examples, a combination of predetermined average tissuethickness data based on the situational awareness of the organ, asdescribed above in greater detail, in combination with volumetricanalysis from the visualization source and CT, MRI, and/or ultrasoundsecondary imaging, if available for the patient, can be utilized toselect a first staple cartridge for the arrangement 4317. Firings ofsubsequent staple cartridges in the arrangement 4317 can use instrumentdata from pervious firings, in addition to the visualization data, tooptimize the firing parameters. The instrument data that could be usedto supplement volume measurements include FTF, FTC, current draw bymotors driving the firing and/or closure, end-effector closure gap, rateof firing, tissue impendence measurements across the jaws, and/or waitor pause time during use of the surgical instrument, for example.

In various examples, visualization data such as, for example, structuredlight data can be used to track surface geometry changes in tissue beingtreated by a surgical instrument (e.g. surgical instrument 4600).Additionally, visualization data such as, for example, spectral data canbe used to track critical structures below the tissue surface. Thestructured data and/or the spectral data can be used to maintain a setinstrument-tissue contact throughout the tissue treatment.

In at least one example, the end effector 4642 of the surgicalinstrument 4600 can be used to grasp tissue between its jaws. Once adesired tissue-instrument contact is confirmed by a user input, forexample, the visualization data for the end effector and surroundingtissue, which are associated with the desired tissue-instrument contact,can be used to automatically maintain the desired tissue-surface contactthroughout at least a portion of the tissue treatment. The desiredtissue-surface contact can be automatically maintained by, for example,slight manipulations to position, orientation, and/or FTC parameters ofthe end effector 4642.

In the event the surgical instrument 4600 is a hand-held surgicalinstrument, position and/or orientation manipulations could be providedto a user in the form of instructions that could be presented on adisplay 4625 (FIG. 22 ) of the surgical instrument 4600, for example. Analert could also be issued by the surgical instrument 4600 when usermanipulations are needed to reestablish the desired tissue-surfacecontact. Meanwhile, non-user manipulations such as, for example,manipulations to the FTC parameters and/or articulation angle can becommunicated to the controller 4620 of the surgical instrument 4600 fromthe surgical hub 2106 or the visualization system 2108, for example. Thecontroller 4620 could then cause the motor driver 4626 to implement thedesired manipulations. In the event the surgical instrument 4600 is asurgical tool coupled to a robotic arm of a robotic system 2110,position and/or orientation manipulations could be communicated to therobotic system 2110 from the surgical hub 2106 or the visualizationsystem 2108, for example.

Referring primarily to FIGS. 36A-36C, a firing of a surgical instrument4600 loaded with a first staple cartridge 4652 in the staple cartridgearrangement 4317 is illustrated. In a first stage, as illustrated inFIG. 36A, a first landmark 4361 and a second landmark 4362 are overlaidonto the surgical resection path 4312. The landmarks 4361, 4362 arespaced apart a distance (d1) defined by the size (e.g. 45) of the staplecartridge 4652 which represents the length of a staple line 4363 to bedeployed by the staple cartridge 4652 onto the surgical resection path4312. The control circuit executing one or more aspects of the process4300 can employ visualization data, as described in greater detailelsewhere herein, to overlay the landmarks 4361, 4362 onto the surgicalresection path 4312, and continuously track and update their positionswith respect to predetermined critical structures such as, for example,anatomical structures 4364, 4365, 4366, 4367.

During firing, as illustrated in FIG. 36B, staples of the staple line4363 are deployed into tissue and the cutting member 4645 is advanced tocut the tissue along the surgical resection path 4312 between thelandmarks 4361, 4362. In various instances, the advancement of thecutting member 4645 causes the tissue being treated to stretch and/orshift. Tissue stretching and/or shifting beyond a predeterminedthreshold indicates that the cutting member 4645 is moving too fastthrough the tissue being treated.

FIG. 37 is a logic flow diagram of a process 4170 depicting a controlprogram or a logic configuration for adjusting a firing speed of asurgical instrument to address tissue stretching/shifting during firing.The process 4170 includes monitoring 4171 a tissue stretch/shift duringfiring of the surgical instrument and adjusting 4173 firing parametersif 4172 the tissue stretch/shift is greater than or equal to apredetermined threshold.

One or more aspects of the process 4170 can be executed by one or moreof the control circuits (e.g. control circuit 132, 400, 410, 420, 602,622, 2108, 4620) described by the present disclosure. In at least oneexample, one or more aspects of the process 4170 are executed by acontrol circuit (e.g. control circuit 400 of FIG. 2A) that includes aprocessor and a memory storing a set of computer-executable instructionsthat, when executed by the processor, cause the processor to perform theone or more aspects of the process 4170. Additionally, or alternatively,one or more aspects of the process 4170 can be executed by acombinational logic circuit (e.g. control circuit 410 of FIG. 2B) and/ora sequential logic circuit (e.g. control circuit 420 of FIG. 2C).Furthermore, the process 4170 can be executed by any suitable circuitrywith any suitable hardware and/or software components that may belocated in or associated with various suitable systems described by thepresent disclosure.

In various examples, a control circuit (e.g. control circuit 132, 400,410, 420, 602, 622, 2108, 4620) executing one or more aspects of theprocess 4170 monitors 4171 tissue stretch/shift during firing of thesurgical instrument 4600 using visualization data from a visualizationsystem (e.g. visualization system 100, 160, 500, 2108). In the exampleillustrated in FIG. 36B, a tissue stretch/shift (d) is monitored 4171 bytracking distortions in a structured light grid projected onto thetissue during firing and/or tracking the landmarks 4364, 4365, 4366,4367, which represent positions of adjacent anatomical structure, usingvisualization data. Additionally, or alternatively, the tissue stretch(d) can be monitored 4171 by tracking the position of the landmark 4362during firing. In the example of FIG. 36B, tissue stretch/shift (d) isthe difference between the distance (d1) between the landmarks 4361,4362 during firing and a distance (d2) between the landmarks 4361, 4362during the firing. In any event, if 4172 the tissue stretch/shift (d) isgreater than or equal to a predetermined threshold, the control circuitadjusts 4173 the firing parameters of the surgical instrument 4600 toreduce the tissue stretch/shift (d). For example, the control circuitmay cause the controller 4620 to reduce the speed of the firing motordrive assembly 4604 by reducing current draw of the firing motor 4602,for example, which reduces the speed of advancement of the cuttingmember 4645. Additionally, or alternatively, the control circuit maycause the controller 4620 to pause the firing motor 4602 for apredetermined period of time to reduce the tissue stretch/shift (d).

Post firing, as illustrated in FIG. 36C, the jaws of the end effector4642 are unclamped, and the stapled tissue shrinks due to the firedstaples of the staple line 4363. FIG. 36C illustrates the projectedstaple line length defined by the distance (d1) and an actual stapleline defined by a distance (d3) less than the distance (d1). Thedifference between the distances d1, d2 represents theshrinkage/shifting distance (d′).

FIG. 38 is a logic flow diagram of a process 4180 depicting a controlprogram or a logic configuration for adjusting a proposed staplecartridge arrangement along a proposed surgical resection path. Theprocess 4180 includes monitoring 4081 stapled tissue shrinkage/shiftingalong a proposed surgical resection path following the firing of astaple cartridge of the proposed arrangement, and adjusting subsequentstaple cartridge positions of the proposed arrangement along theproposed surgical resection path.

One or more aspects of the process 4180 can be executed by one or moreof the control circuits (e.g. control circuit 132, 400, 410, 420, 602,622, 2108, 4620) described by the present disclosure. In at least oneexample, one or more aspects of the process 4180 are executed by acontrol circuit (e.g. control circuit 400 of FIG. 2A) that includes aprocessor and a memory storing a set of computer-executable instructionsthat, when executed by the processor, cause the processor to perform theone or more aspects of the process 4180. Additionally, or alternatively,one or more aspects of the process 4180 can be executed by acombinational logic circuit (e.g. control circuit 410 of FIG. 2B) and/ora sequential logic circuit (e.g. control circuit 420 of FIG. 2C).Furthermore, the process 4180 can be executed by any suitable circuitrywith any suitable hardware and/or software components that may belocated in or associated with various suitable systems described by thepresent disclosure.

In various examples, a control circuit (e.g. control circuit 132, 400,410, 420, 602, 622, 2108, 4620) executing one or more aspects of theprocess 4180 monitors 4181 shrinkage/shifting of a stapled tissue alonga proposed resection path 4312. In the example illustrated in FIG. 36C,a staple line 4363 is deployed into the tissue between the landmarks4361, 4362 from a staple cartridge of the staple cartridge arrangement4317. When the jaws of the end effector 4642 are unclamped, the stapledtissue shrinks/shifts a distance (d′). The distance (d′) is thedifference between the distance (d1) between the landmarks 4361, 4362pre-firing, which represents a length of the staple line 4361 proposedby the arrangement 4317, and a distance (d3) representing the actuallength of the staple line 4363.

To avoid gaps between consecutive staple lines, the control circuitadjusts subsequent staple cartridge positions of the proposedarrangement 4317 along the proposed surgical resection path 4312. Forexample, as illustrated in FIG. 36C an originally proposed staple line4368 is removed and replaced by an updated staple line 4369 that extendsthrough, or covers, the gap defined by the distance (d′). In variousaspects, a tissue shrinkage/shift (d′) is monitored 4181 by trackingdistortions in a structured light grid projected onto the tissue afterthe jaws of the end effector 4642 are unclamped and/or tracking thelandmarks 4364, 4365, 4366, 4367, which represent positions of adjacentanatomical structure, using visualization data. Additionally, oralternatively, the tissue shrinkage distance (d′) can be monitored 4181by tracking the position of the landmark 4362.

In various aspects, it may be desirable to corroborate visualizationdata derived from a surgical visualization system (e.g. visualizationsystem 100, 160, 500, 2108) using non-visualization data fromnon-visualization systems and vice versa. In one example, anon-visualization system can include a ventilator, which can beconfigured to measure non-visualization data, such as volume, pressure,partial pressure of carbon dioxide (PCO₂), partial pressure of oxygen(PO₂), etc., of a patient's lungs. Corroborating visualization data withnon-visualization data provides a clinician with greater confidence thatthe visualization data derived from the visualization system isaccurate. In addition, corroborating the visualization data with thenon-visualization data allows a clinician to better identifypost-operative complications, as well as determine the overallefficiency of the organ, as will described in greater detail below. Thecorroboration may also be helpful in segmentectomy or complicatedlobectomies without fissures.

In various aspects, a clinician may need to resect a portion of apatient's organ to remove a critical structure, such as a tumor, and/orother tissue. In one example, the patient's organ can be the right lung.A clinician may need to resect a portion of the patient's right lung inorder to remove unhealthy tissue. However, the clinician may not want toremove too much of the patient's lung during the surgical procedure inorder to ensure the lung's functionality is not too compromised. Thelung's functionality can be assessed based on peak lung volume perbreath, which represents peak lung capacity. In determining how much ofthe lung can be safely removed, the clinician is limited by apredetermined peak lung-capacity reduction beyond which the lung losesits viability, necessitating a full organ resection.

In at least one example, the surface area and/or volume of the lung isestimated from visualization data from surgical visualization system(e.g. visualization system 100, 160, 500, 2108). The lung surface areaand/or volume can be estimated at peak lung capacity, or peak lungvolume per breath. In at least one example, the lung surface area and/orvolume can be estimated at multiple points throughout theinhalation/exhalation cycle. In at least one aspect, prior to resectionof a portion of the lung, visualization data and non-visualization datacan be utilized to correlate the surface area and/or volume of the lungdetermined by the visualization system with lung capacity as determinedby a ventilator. Correlation data can be employed in developing amathematical relation between the surface area and/or volume of thelung, as derived from visualization data, and the lung capacity, asdetermined by a ventilator, for example. The relation can be employed inestimating the size of a lung portion that could be removed whilemaintaining the peak lung-capacity reduction at a value less than orequal to a predetermined threshold that sustains the viability of thelung.

FIG. 39 illustrates a logic flow diagram of a process 4750 for proposinga surgical resection of an organ portion, in accordance with at leastone aspect of the present disclosure. The process 4750 is generallyexecuted during a surgical procedure. The process 4750 may includeproposing 4752 a portion of an organ to resect based on visualizationdata from the surgical visualization system, wherein resection of theportion is configured to yield an estimated capacity reduction of theorgan. The process 4750 may further include determining 4754 a firstvalue of a non-visualization parameter of the organ prior to resectionof the portion and determining 4756 a second value of thenon-visualization parameter of the organ after resection of the portion.Additionally, in certain examples, the process 4750 may further includecorroborating 4758 the predetermined capacity reduction based on thefirst value of the non-visualization parameter and the second value ofthe non-visualization parameter.

One or more aspects of the process 4750 can be executed by one or moreof the control circuits (e.g. control circuit 132, 400, 410, 420, 602,622, 2108, 4620) described by the present disclosure. In at least oneexample, one or more aspects of the process 4750 are executed by acontrol circuit (e.g. control circuit 400 of FIG. 2A) that includes aprocessor and a memory storing a set of computer-executable instructionsthat, when executed by the processor, cause the processor to perform theone or more aspects of the process 4750. Additionally, or alternatively,one or more aspects of the process 4750 can be executed by acombinational logic circuit (e.g. control circuit 410 of FIG. 2B) and/ora sequential logic circuit (e.g. control circuit 420 of FIG. 2C).Furthermore, one or more aspects of the process 4750 can be executed byany suitable circuitry with any suitable hardware and/or softwarecomponents that may be located in or associated with various suitablesystems described by the present disclosure.

In various aspects, the process 4750 can be implemented by acomputer-implemented interactive surgical system 2100 (FIG. 19 ) thatincludes one or more surgical systems 2102 and a cloud-based system(e.g., the cloud 2104 that may include a remote server 2113 coupled to astorage device 2105). Each surgical system 2102 includes at least onesurgical hub 2106 in communication with the cloud 2104 that may includea remote server 2113. The control circuit executing one or more aspectsof the process 4750 can be a component of a visualization system (e.g.visualization system 100, 160, 500, 2108).

FIG. 41A illustrates a set of patient's lungs 4780. In one embodiment, aclinician can utilize an imaging device 4782 to emit 4784 a pattern 4785of light onto the surface of the patient's right lung 4786, such asstripes, grid lines, and/or dots, to enable the determination of thetopography or landscape of the surface of the patient's right lung 4786.The imaging device can be similar in various respects to imaging device120 (FIG. 1 ). As described elsewhere herein, projected light arrays canbe employed to determine the shape defined by the surface of thepatient's right lung 4786, and/or motion of the patient's right lung4786 intraoperatively. In one embodiment, the imaging device 4782 can becoupled to the structured light source 152 of control system 133. In oneembodiment, a surgical visualization system, such as surgicalvisualization system 100, could utilize the surface mapping logic 136 ofcontrol circuit 133, described elsewhere herein, to determine thetopography or landscape of the surface of the patient's right lung 4786.

A clinician may provide a type of procedure that is to be performed,such as an upper right lobectomy, to a surgical system, such as surgicalsystem 2100. In addition to providing the surgical procedure to beperformed, the clinician may provide the surgical system with a maximumdesired capacity of the organ to be removed during the surgicalprocedure. Based on the visualization data obtained from the imagingdevice 4782, the type of surgical procedure to be performed, and themaximum desired capacity to be removed, the surgical system can proposea resection path 4788 to remove a portion of the right lung 4790 thatsatisfies all of the clinician's inputs. Other methods of proposingsurgical resection paths are described elsewhere herein. Any number ofadditional parameters can be considered by the surgical system in orderto propose the resection path 4788.

In various instances, it may be desirable to ensure that the volume ofthe organ resected yields the desired capacity reduction from thepatient's organ. In order to corroborate that the volume resected yieldsthe desired capacity reduction, non-visualization data fromnon-visualization systems can be utilized. In one embodiment, aventilator can be utilized to measure peak lung capacity in a patientover time.

In at least one example, a clinician may utilize the surgical system2100 in a surgical procedure to remove a lung tumor. The control circuitmay identify the tumor from visualization data, as described above inconnection with FIGS. 13A-13E and may propose a surgical resection paththat provides a safe margin around the tumor, as described above inconnection with FIGS. 29-38 . The control circuit may further estimate avolume of the lung at peak lung capacity. A ventilator can be utilizedto measure the peak lung capacity prior to the surgical procedure. Usinga predetermined mathematical correlation between visually estimated lungvolume and lung capacity as detected by the ventilator, the controlcircuit is able to estimate a peak lung-capacity reduction associatedwith removing a portion of the lung, which includes the tumor and a safemargin of tissue around it. If the estimated lung capacity reduction isbeyond a predetermined safety threshold, the control circuit can alertthe clinician and/or propose a different surgical resection path thatyields a lesser reduction in the lung capacity.

FIG. 41C illustrates a graph 4800 measuring a patient's peak lungcapacity over time. Prior to resection of the portion of organ (t₁), aventilator can measure peak lung capacity. In FIG. 41C, at time t₁ priorto resection of the portion 4790, the peak lung capacity is measured asbeing 6 L. In the example described above where the surgical procedureto be performed is an upper right lobectomy, a clinician may desire toonly remove a volume of the patient's lung that yields a predeterminedcapacity reduction such that the patient's ability to breath is notcompromised. In one embodiment, a clinician may desire to remove aportion yielding up to about 17% reduction of the patient's peak lungcapacity, for example. Based on the surgical procedure and the desiredcapacity reduction, the surgical system can propose a surgical resectionpath 4788 that achieves removal of the lung portion while maintain peaklung capacity at a value greater than or equal to 83% of the un-resectedpeak lung capacity.

Utilizing ventilator data, as shown in FIG. 41C, the clinician canmonitor the patient's peak lung capacity over time, such as prior tosection 4802 and after resection 4804 of the portion of the lung 4790.At time t₂, the portion of the lung 4790 is resected along the proposedresection path 4788. As a result, the peak lung capacity measured by theventilator drops. A clinician can corroborate with the ventilator data(pre-resection peak lung volume 4802 and post resection peak lung volume4804) to ensure that the volume of the lung resected yields the desiredcapacity reduction from the lungs. As shown in FIG. 41C, afterresection, the peak lung capacity has dropped to 5 L, which isapproximately a 17% drop in peak lung capacity, which is approximatelythe same as the desired reduction in capacity. Using the ventilatordata, the clinician has greater confidence that the actual reduction incapacity is aligned with the desired reduction in capacity achieved bythe proposed surgical resection path 4788. In other embodiments, wherethere is a discrepancy between the non-visualization data and thevisualization data, such as a larger drop in peak lung capacity thanexpected (too much lung resected) or a smaller drop in peak lungcapacity than expected (not enough lung resected), the clinician candetermine if appropriate action should be taken.

Referring now to FIG. 41B, the patient's right lung 4792 is shown afterresection of the portion 4790. After resection of the portion 4790, theclinician may have inadvertently caused an air leak 4794, which resultsin air leaking into the space between the lung 4794 and chest wall,resulting in a pneumothorax 4796. As a result of the aft leak 4794, thepatient's peak lung volume per breath will steadily diminish over timeas the right lung 4792 collapses, Dynamic surface area/volumetricanalysis of the lung can be performed using the visualization dataderived from a visualization system (e.g. visualization system 100, 160,500, 2108) to detect an aft leak by visually tracking a change in thevolume of the lung. The volume and/or surface area of the lung can betracked visually at one or more points during the inhalation/exhalationcycle to detect a volume change indicative of the air leak 4794. In oneembodiment, as discussed above, projected light arrays from the imagingdevice 4782 can be employed to monitor motion of the patient's rightlung 4786 over time, such as monitoring a decrease in size. In anotherembodiment, the surgical visualization system could utilize surfacemapping logic, such as surface mapping logic 136, to determine thetopography or landscape of the surface of the patient's right lung 4786and monitor changes in the topography or landscape over time.

In one aspect, the clinician can utilize the non-visualization system,such as the ventilator, to corroborate the reduction in volume detectedby the visualization system. Referring again to FIG. 41C, as describedabove, a patient's peak lung capacity can be measured prior to resectionof the portion of the lung 4802 and after resection of the portion tocorroborate the desired reduction in capacity aligns with the actualreduction in capacity of the lung. In the example described above wherean air leak inadvertently occurred, peak lung capacity may steadilydecline over time 4806, In one instance, at time t₂ immediately afterresection of the portion, a clinician may note the peak lung capacityhas dropped from 6 L to 5 L, which is approximately aligned with thedesired reduction in lung capacity. After resection of the portion, thesurgical visualization system can monitor the patient's lung volume overtime. If the surgical visualization system determines that there is achange in volume, the clinician can measure peak lung capacity again,such as at time t₃. At time t₃, the clinician may note that the peaklung capacity has dropped from 5 L to 4 L, which corroborates the datadetermined from the visualization system, which indicates that there maybe an air leak in the right lung 4792.

In addition, the control circuit can be configured measure organefficiency based on the visualization data and the non-visualizationdata. In one aspect, the organ efficiency can be determined by comparingvisualization data to a difference in the non-visualization data beforeand after resection of the portion. In one example, the visualizationsystem can generate the resection path to cause a 17% reduction in peaklung capacity. The ventilator can be configured to measure peak lungcapacity before resection of the portion and after the resection of theportion. In the instance illustrated in FIG. 41C, there is approximatelya 17% drop in peak lung capacity (6 L to 5 L). As there is a near 1:1drop in actual lung capacity (17%) against desired lung capacity (17%),the clinician can determine that the lung is functionally efficient. Inanother example, the visualization system can generate the resectionpath to cause a 17% reduction in peak lung capacity. However, theventilator may measure a drop in peak lung capacity that is greater than17%, such as 25%, as an example. In this instance, the clinician candetermine that the lung is not functionally efficient as resecting theportion of the lung resulted in a larger drop in peak lung capacity thanwould be expected.

FIG. 40 illustrates a logic flow diagram of a process 4760 forestimating a capacity reduction of an organ resulting from the removalof a selected portion of the organ, in accordance with at least oneaspect of the present disclosure. The process 4760 is similar in manyrespects to the process 4750. Unlike the process 4750, however, theprocess 4760 relies on the clinician to select or propose a surgicalresection path for removing a portion of an organ during a surgicalprocedure. The process 4760 includes receiving 4762 an input from a userindicative of a portion of an organ to resect. The process 4760 furtherincludes estimating 4764 a capacity reduction of the organ that wouldresult from removing the portion. In at least one example, the organ isa patient's lung, and the estimated 4762 capacity reduction is areduction in the peak lung volume per breath of the patient's lung.Visualization data from a surgical visualization system (e.g.visualization system 100, 160, 500, 2108) can be employed to estimatethe capacity reduction corresponding to removal of the portion. Theprocess 4760 may further include determining 4766 a first value of anon-visualization parameter of the organ prior to resection of theportion and determining 4768 a second value of the non-visualizationparameter of the organ after resection of the portion. Finally, theprocess 4760 may further include corroborating 4768 the estimatedcapacity reduction of the organ based on the first value of thenon-visualization parameter and the second value of thenon-visualization parameter.

One or more aspects of the process 4760 can be executed by one or moreof the control circuits (e.g. control circuit 132, 400, 410, 420, 602,622, 2108, 4620) described by the present disclosure. In at least oneexample, one or more aspects of the process 4760 are executed by acontrol circuit (e.g. control circuit 400 of FIG. 2A) that includes aprocessor and a memory storing a set of computer-executable instructionsthat, when executed by the processor, cause the processor to perform theone or more aspects of the process 4760. Additionally, or alternatively,one or more aspects of the process 4760 can be executed by acombinational logic circuit (e.g. control circuit 410 of FIG. 2B) and/ora sequential logic circuit (e.g. control circuit 420 of FIG. 2C).Furthermore, one or more aspects of the process 4760 can be executed byany suitable circuitry with any suitable hardware and/or softwarecomponents that may be located in or associated with various suitablesystems described by the present disclosure.

In various aspects, the process 4760 can be implemented by acomputer-implemented interactive surgical system 2100 (FIG. 19 ) thatincludes one or more surgical systems 2102 and a cloud-based system(e.g., the cloud 2104 that may include a remote server 2113 coupled to astorage device 2105). Each surgical system 2102 includes at least onesurgical hub 2106 in communication with the cloud 2104 that may includea remote server 2113. The control circuit executing one or more aspectsof the process 4760 can be a component of a visualization system (e.g.visualization system 100, 160, 500, 2108).

In one instance, a clinician may provide an input to the surgicalvisualization system, such as surgical visualization system 2100,indicative of a portion of an organ to resect. In one instance, aclinician may draw a resection path on a virtual 3D construct of theorgan, such as the virtual 3D construct generated 4104 during process4100. In other instances, the visualization system can overlay aprocedure layout plan, described in greater detail elsewhere herein,which can be in the form of a recommended treatment path. Therecommended treatment path can based on a type of surgical procedurebeing performed. In one embodiment, the recommended treatment path canpropose different starting points and propose different resection pathsthat the clinician can select between, similar to the resection paths4146, 4147, 4148 described elsewhere herein. The proposed resectionpaths can be determined by the visualization system such that certaincritical structures, such as arteries, are avoided. The clinician canselect the proposed resection paths until a desired resection path toremove the portion of the organ is complete.

In one instance, the surgical visualization system can determine anestimated capacity reduction of the organ based on the selectedresection path. After resecting the predetermined portion along theresection path, the clinician may desire to use non-visualization datato corroborate that the actual reduction in capacity corresponds to theestimated capacity reduction based on the visualization data. In oneembodiment, this corroboration can be done using a similar procedure asdescribed above in regard to process 4750 where the organ is a lung. Theclinician can measure peak lung capacity before 4802 and after 4804resection of the lung and compare the change in peak lung capacity todetermine an actual drop in peak lung capacity. In one example, thesurgical visualization system may estimate a 17% reduction in peak lungcapacity based on the clinician's proposed resection path. Prior toresection, the clinician may note a peak lung capacity of 6 L (time t₁).After resection, the clinician may note a peak lung capacity of 5 L(time t₂), which is approximately a 17% drop in peak lung capacity.Using this non-visualization/ventilator data, the clinician has greaterconfidence that the actual reduction in capacity is aligned with theestimated reduction in capacity. In other instances, where there is adiscrepancy between the non-visualization data and the visualizationdata, such as a larger drop in peak lung capacity than expected (toomuch lung resected) or a smaller drop in peak lung capacity thanexpected (not enough lung resected), the clinician can determine ifappropriate action should be taken.

In addition, the control circuit can be configured to measure organefficiency based on the visualization data and the non-visualizationdata. In one aspect, the organ efficiency can be determined by comparingvisualization data to a difference in the non-visualization data beforeand after resection of the portion. In one example, the visualizationsystem may estimate a 17% reduction in peak lung capacity based on theclinician's desired resection path. The ventilator can be configured tomeasure peak lung capacity before resection of the portion and after theresection of the portion. In the instance illustrated in FIG. 41C, thereis approximately a 17% drop in peak lung capacity (6 L to 5 L). As thereis a near 1:1 drop in actual lung capacity (17%) against the estimatedlung capacity (17%), the clinician can determine that the lung isfunctionally efficient. In another example, the visualization system mayestimate a 17% reduction in peak lung capacity based on the clinician'sdesired resection path. However, the ventilator may measure a drop inpeak lung capacity that is greater than 17%, such as 25%, as an example.In this instance, the clinician can determine that the lung is notfunctionally efficient as resecting the portion of the lung resulted ina larger drop in peak lung capacity than would be expected.

As described above in regard to processes 4750, 4760, a clinician cancorroborate visualization data with non-visualization data, such as byusing a ventilator to measure peak lung volume before and afterresection of a portion of the lung. Another example of corroboratingvisualization data with non-visualization data is through capnography.

FIG. 42 illustrates a graph 4810 measuring partial pressure of carbondioxide (PCO₂) exhaled by a patient over time. In other instances,partial pressure of oxygen (PO₂) exhaled by a patient can be measuredover time. The graph 4810 illustrates PCO₂ measured prior to resection4812, immediately following resection 4814, and a minute after resection4816. In FIG. 42 , prior to resection 4812, PCO₂ is measured to be ˜40mmHg (at time t₁). In the examples described above where the surgicalprocedure to be performed is an upper right lobectomy, a visualizationsystem may desire or estimate a 17% decrease in lung capacity. The PCO₂levels measured by the ventilator can be used to corroborate thisdesired or estimated reduction in capacity.

Utilizing the ventilator data, as shown in FIG. 42 , the clinician canmonitor the patient's PCO₂ over time, such as prior to section 4812 andimmediately after resection 4814 of the portion of the lung 4790. Attime t₂, the portion of the lung 4790 has been resected, and as aresult, the PCO₂ measured by the ventilator can drop 4818. A cliniciancan corroborate with the ventilator data (pre-resection 4812 PCO₂ (att₁) and post resection 4814 PCO₂ (at t₂)) to ensure that the actualreduction in capacity of the lung aligns with the estimated or desiredreduction in capacity of the lungs. As shown in FIG. 42 , immediatelyafter resection 4814 of the portion 4790, the PCO₂ drops 4812, which canbe measured as an approximate 17% drop in PCO₂ (˜33.2 mmHg). Using thisnon-visualization/ventilator data, the clinician has greater confidencethat the actual reduction in capacity of the lung aligns with thedesired or estimated reduction in capacity of the lung.

In other instances, the clinician can utilize the non-visualization/PCO₂data to determine discrepancies when compared to the visualization data.In one instance, immediately after resection 4814 of the portion 4790,at time t₂, the PCO₂ may be measured at 4820, which is higher than thePCO₂ measured prior to resection 4812. The increase in PCO₂ may be theresult of a bronchus being inadvertently occluded during the surgicalprocedure, causing CO₂ to build up within the patient. In anotherinstance, immediately after resection 4814 of the portion 4790, at timet₂, the PCO₂ may be measured at 4822, which is lower than the PCO₂measured prior to resection 4812 and lower than expected. The decreasein PCO₂ may be a result of a vessel being inadvertently occluded duringthe surgical procedure, causing less O₂ being delivered to the body, andthus, less CO₂ being produced. In either case, the clinician can takeappropriate action to remedy the situation.

The changes in PCO₂ can also be measured at a time other thanimmediately resection 4814, such as a minute after resection 4816 (suchas at time t₃). At time t₃, other body functions (such as kidneys)compensate for the changes in PCO₂ as a result of the resection. In thissituation, PCO₂ can be measured to be ˜40 mm Hg, or approximately thesame that was measured prior to resection 4812. At time t₃, differencesmeasured between the PCO₂ prior to resection 4812 can indicate theinadvertent occlusions discussed above. For example, at time t₃, PCO₂may be measured 4824 as being higher than prior to resection 4812,indicating a possible inadvertently occluded bronchus, or PCO₂ may bemeasured 4826 as being lower than prior to resection 4812, indicating apossible inadvertently occluded vessel.

In addition, the control circuit can be configured measure organefficiency based on the visualization data and the non-visualizationdata. In one aspect, the organ efficiency can be determined by comparingvisualization data to a difference in the non-visualization data beforeand after resection of the portion. In one example, the visualizationsystem may estimate a 17% reduction in capacity of the lung based on aclinician's desired resection path. The ventilator can be configured tomeasure PCO₂ before resection of the portion and after the resection ofthe portion. In the embodiment illustrated in FIG. 42 , there isapproximately a 17% drop in PCO₂ immediately after resection 4814. Asthere is a near 1:1 drop in PCO₂ (17%) against estimated reduction incapacity of the lung (17%), the clinician can determine that the lung isfunctionally efficient. In another example, the visualization system mayestimate a 17% reduction in capacity of the lung based on theclinician's desired resection path. However, the ventilator may measurea drop in PCO₂ that is greater than 17%, such as 25%, as an example. Inthis instance, the clinician can determine that the lung is notfunctionally efficient as resecting the portion of the lung resulted ina larger drop in PCO₂ than would be expected.

In addition to peak lung volume and PCO₂ measurements described above,other non-visualization parameters that could be utilized includingblood pressure or EKG data. EKG data would provide approximate frequencydata on deformation of arteries. This frequency data with surfacegeometry changes within a similar frequency range could help identifycritical vascular structures.

As described above, it may be desirable to utilize non-visualizationdata from non-visualization systems to corroborate visualization dataderived from a surgical visualization system (e.g. visualization system100, 160, 500, 2108). In the examples described above, thenon-visualization data provides a means for corroborating visualizationdata after a portion of an organ has already been resected. In someinstances, it may be desirable to supplement visualization data withnon-visualization data prior to a portion of an organ being resected. Inone example, non-visualization data could be used with visualizationdata to help determine characteristics of an organ that is going to beoperated on. In one aspect, the characteristic could be an abnormalityof the organ tissue that may not be suitable for cutting. Thenon-visualization data and the visualization data could help inform thesurgical visualization system and the clinician about areas to avoidwhen planning out a resection path for the organ. This may be helpful insegmentectomy or complicated lobectomies without fissures.

FIG. 43 illustrates a logic flow diagram of a process 4850 for detectinga tissue abnormality based on visualization data and non-visualizationdata, in accordance with at least one aspect of the present disclosure.The process 4850 is generally executed during a surgical procedure. Theprocess 4850 may include receiving 4852 first visualization data fromthe surgical visualization system in a first state of an organ anddetermining 4854 a first value of a non-visualization parameter of theorgan in the first state. The process 4850 may further include receiving4856 second visualization data from the surgical visualization system ina second state of the organ and determining 4858 a second value of thenon-visualization parameter of the organ in the second state. Theprocess may also include detecting 4860 a tissue abnormality based onthe first visualization data, the second visualization data, the firstvalue of a non-visualization parameter, and the second value of thenon-visualization parameter.

One or more aspects of the process 4850 can be executed by one or moreof the control circuits (e.g. control circuit 132, 400, 410, 420, 602,622, 2108, 4620) described by the present disclosure. In at least oneexample, one or more aspects of the process 4850 are executed by acontrol circuit (e.g. control circuit 400 of FIG. 2A) that includes aprocessor and a memory storing a set of computer-executable instructionsthat, when executed by the processor, cause the processor to perform theone or more aspects of the process 4850. Additionally, or alternatively,one or more aspects of the process 4850 can be executed by acombinational logic circuit (e.g. control circuit 410 of FIG. 2B) and/ora sequential logic circuit (e.g. control circuit 420 of FIG. 2C).Furthermore, one or more aspects of the process 4850 can be executed byany suitable circuitry with any suitable hardware and/or softwarecomponents that may be located in or associated with various suitablesystems described by the present disclosure.

In various aspects, the process 4850 can be implemented by acomputer-implemented interactive surgical system 2100 (FIG. 19 ) thatincludes one or more surgical systems 2102 and a cloud-based system(e.g., the cloud 2104 that may include a remote server 2113 coupled to astorage device 2105). Each surgical system 2102 includes at least onesurgical hub 2106 in communication with the cloud 2104 that may includea remote server 2113. The control circuit executing one or more aspectsof the process 4850 can be a component of a visualization system (e.g.visualization system 100, 160, 500, 2108).

FIG. 44A illustrates a right lung 4870 of a patient in a first state4862. In one example, the first state 4862 could be a deflated state. Inanother example, the first state 4862 could be a collapsed state. Animaging device 4872 is shown inserted through a cavity 4874 in thepatient's chest wall 4876. A clinician can utilize the imaging device4872 to emit 4880 a pattern of light 4882 onto the surface of the rightlung 4870, such as stripes, grid lines, and/or dots, to enable thedetermination of the topography or landscape of the surface of apatient's right lung 4870. The imaging device can be similar in variousrespects to imaging device 120 (FIG. 1 ). As described elsewhere herein,projected light arrays are employed to determine the shape defined bythe surface of the patient's right lung 4870, and/or motion of thepatient's right lung 4870 intraoperatively. In one embodiment, theimaging device 4782 can be coupled to the structured light source 152 ofcontrol system 133. In one embodiment, a surgical visualization system,such as surgical visualization system 100, could utilize the surfacemapping logic 136 of control circuit 133, described elsewhere herein, todetermine the topography or landscape of the surface of the patient'sright lung 4786. In the first state 4862 of the right lung 4870, aventilator can be used to measure parameters of the right lung 4870,such as a first state pressure (P₁ or positive end-expiratory pressure(PEEP)) or a first state volume (V₁).

FIG. 44B illustrates the right lung 4870 of the patient in a secondstate 4864. In one example, the second state 4864 could be a partiallyinflated state. In another example, the second state 4864 could be acompleted inflated state. The imaging device 4872 can be configured tocontinue emitting 4880 the pattern of light 4882 onto the surface of thelung 4870 to enable the determination of the topography or landscape ofthe surface of the patient's right lung 4870 in the second state 4864.In the second state 4864 of the right lung 4870, the ventilator can beused to measure parameters of the right lung 4870, such as second statepressure (P₂) which is larger than the first state 4862 pressure P₁ anda second state volume (V₂) which is larger than the first state 4862volume V₁.

Based on the surface topography determined from the surgicalvisualization system and imagine device 4872, along with thenon-visualization data determined from the ventilator (pressure/volume),the surgical visualization system can be configured to determineabnormalities of the tissue of the right lung 4870. In one example, inthe first state 4862, the imaging device 4872 can determine the firststate 4662 topography of the right lung 4870 (shown in FIG. 44A and ingreater detail in FIG. 44C) and the ventilator could determine a firststate pressure/volume. In the second state 4864, the imaging device 4872can determine the second state 4864 topography of the right lung 4870(shown in FIG. 44B and in greater detail in FIG. 44D) and the ventilatorcould determine a second state pressure/volume, which are greater thanthe first state pressure/volume due to the lung being partially orcompleted inflated. Based on the known increase in pressure/volume, thevisualization system can be configured to monitor changes in thetopography of the right lung 4870 that are in accordance with the knownincreases in pressure/volume. In one aspect, this pressure/volumemeasurement from the ventilator can be correlated with surfacedeformation of the right lung 4870 to identify regions of disease withinthe lung to help inform stapler placement.

In one aspect, referring to FIGS. 44B and 44D, where pressure hasincreased from P₁ to P₂ (and volume has increased from V₁ to V₂), thesurface topography determined from the structured light 4880 has changedcompared to the first state 4862. In one example, the pattern of light4882 can be dots and the dots have been spaced apart by distances fromeach other as the lung size increases. In another example, the patternof light 4882 can be grid lines and the grid lines have been spacedapart or contoured as the lung size increases. Based on the knownpressure increase, the imaging device can determine regions 4886 thatdid not change in accordance with the known pressure and volumeincreases. For example, where the imaging device 4872 emits a pattern4882 of grid lines and dots onto the surface of the right lung 4870(shown in FIGS. 6A-6D), the visualization system can be configured tomonitor the contours of the grid lines and the positioning of the dotsrelative to one another for known pressure/volume increases. Where thevisualization systems notices irregularities in the spacing of the dotsor the positioning and curvature of the gridlines, the visualizationsystem can determine that those regions correspond to potentialabnormalities of the tissue, such as subsurface voids 4886 or regionswhere a critical structure 4884, such as a tumor, may be positioned. Inone embodiment, referring to process 4100 where the process 4100identifies 4105 anatomical structures of at least a portion of theanatomical organ, which are relevant to the surgical procedure, theprocess 4100 could identify abnormalities as described hereinabove andoverlay these abnormalities onto the 3D construct.

In one example, a patient may have emphysema, which is a lung conditionthat causes shortness of breath. In people with emphysema, the air sacsin the lungs (alveoli) are damaged and, over time, the inner walls ofthe air sacs weaken and rupture, creating larger air spaces instead ofmany small ones. This reduces the internal surface area for of thelungs, used for O₂/CO₂ exchange, which therefore, reduces the amount ofoxygen that reaches the bloodstream. In addition, the damaged alveoli donot function properly and old air becomes trapped, leaving no room forfresh, oxygen-rich air to enter. The voids within the lung in emphysemapatients represent regions with less tissue thickness and can thereforeinfluence stapling outcomes in the region. The tissue is also weakened,which results in the alveoli rupturing, and is less able to hold staplesthat pass through them.

As the lung with emphysema inflates and deflates, the regions withsubsurface voids will have different amounts of deformation as thepressure changes compared to healthy tissue. Utilizing theabove-described process 4850, these weak tissue regions with subsurfacevoids can be detected to inform the clinician that they should avoidstapling through these regions, which can decrease the likelihood ofpost-operative air leaks. The tissue deformation capabilities of thisprocess 4850 would permit the detection of these differences allowingthe surgeon to be guided in the placement of the stapler.

In a second example, a patient may have cancer. Prior to the procedure,the tumor may have been irradiated, which damages the tissue as well asthe surrounding tissue. Irradiation changes the properties of thetissue, often making it much stiffer and less compressible. If thesurgeon needs to staple across this tissue, the change in tissuestiffness should be considered when selecting a staple reload type (e.g.stiffer tissue will require a taller formed staple).

As the lung inflates and deflates, the regions with stiffer tissues willhave different amounts of deformation compared to healthy tissue as thelung is less compliant in these regions. The tissue deformationcapabilities of this process 4850 would permit the detection of thesedifferences allowing the surgeon to be guided in the placement of thestapler, as well as and the selection of the cartridge/reload color.

In another aspect, a memory, such as memory 134, may be configured tostore surface topographies of lungs for known pressures and volumes. Inthis instance, an imaging device, such as imaging device 4872, can emita pattern of light to determine the topography of the surface of thepatient's lung at a first known pressure or volume. The surgical system,such as surgical system 2100, can be configured to compare the firstdetermined topography at the known first pressure or volume totopographies stored in the memory 134 for the given first pressure orvolume. Based on the comparison, the visualization system can beconfigured to indicate potential abnormalities of the tissue in only asingle state. The visualization system can note these potential areas ofabnormalities and proceed with determining the topography of the surfaceof the patient's lung at a second known pressure or volume. Thevisualization system can compare the second determined surfacetopography to topographies stored in the memory for the second givenpressure or volume, as well as the topography determined at the firstknown pressure or volume. If the visualization system determinespotential areas of abnormalities that overlap with first determinedpotential areas of abnormalities, the visualization system can beconfigured to indicate the overlapping areas as potential abnormalitieswith greater confidence based on the comparisons at the first and secondknown pressure or volumes.

In addition to the above, a PO₂ measurement from a ventilator could becompared with the inflation lung volume, such as V₂ versus the deflatedlung volume, such as V₁. The volume comparison could utilize EKG data tocompare inhalation and exhalation that could be compared with bloodoxygenation. This could also be compared with anesthesia gas exchangemeasurement to determine breathing volume versus oxygen intake versussedation. In addition, EKG data could provide approximate frequency dataon deformation of arteries. This frequency data with surface geometrychanges within a similar frequency range could help identify criticalvascular structures.

In another embodiment, current tracking/procedure information can becompared with a pre-surgical planning simulation. In challenging orhigh-risk procedures, the clinician can utilize pre-operative patientscans to simulate a surgical approach. This dataset could be compared inthe display, such as display 146, against real time measurements to helpenable a surgeon to follow a particular pre-surgical plan based ontraining runs. This would require the ability to match fiduciallandmarks between pre-operative scans/simulations and currentvisualization. One method may simply use boundary tracking of an object.Insights into how current device-tissue interaction compares againstprevious interactions (per patient) or anticipated interaction (databaseor past patients) for tissue type discernment, relative tissuedeformation assessment, or sub-surface structural differences can bestored in memory, such as memory 134.

In one embodiment, surface geometry could be a function of a toolposition. A surface reference can be selected when no change in surfacegeometry is measured per change in tool position. As the tool interactswith tissue and deforms the surface geometry, the change in surfacegeometry as a function in tool position can be computed by the surgicalsystem. For a given change in tool position upon contact with thetissue, the change in tissue geometry may be different in regions withsub-surface structures, such as critical structure 4884, than in regionswithout such structures, such as sub-surface voids 4886. In one example,such as thoracic procedures, this could be above an airway versus beingin parenchyma only. A running average of the change in tool positionversus change in surface geometry can be computed by the surgical systemusing the surgical visualization system for the given patient to givenpatient-specific differences, or the value can be compared to a secondset of previously collected data.

Example Clinical Applications

Various surgical visualization systems disclosed herein may be employedin one or more of the following clinical applications. The followingclinical applications are non-exhaustive and merely illustrativeapplications for one or more of the various surgical visualizationsystems disclosed herein.

A surgical visualization system, as disclosed herein, can be employed ina number of different types of procedures for different medicalspecialties, such as urology, gynecology, oncology, colorectal,thoracic, bariatric/gastric, and hepato-pancreato-biliary (HPB), forexample. In urological procedures, such as a prostatectomy, for example,the ureter may be detected in fat or connective tissue and/or nerves maybe detected in fat, for example. In gynecological oncology procedures,such as a hysterectomy, for example, and in colorectal procedures, suchas a low anterior resection (LAR) procedure, for example, the ureter maybe detected in fat and/or in connective tissue, for example. In thoracicprocedures, such as a lobectomy, for example, a vessel may be detectedin the lung or in connective tissue and/or a nerve may be detected inconnective tissue (e.g., an esophagostomy). In bariatric procedures, avessel may be detected in fat. In HPB procedures, such as a hepatectomyor pancreatectomy, for example, a vessel may be detected in fat(extrahepatic), in connective tissue (extrahepatic), and the bile ductmay be detected in parenchyma (liver or pancreas) tissue.

In one example, a clinician may want to remove an endometrial myoma.From a preoperative magnetic resonance imaging (MRI) scan, the clinicianmay know that the endometrial myoma is located on the surface of thebowel. Therefore, the clinician may want to know, intraoperatively, whattissue constitute a portion of the bowel and what tissue constitutes aportion of the rectum. In such instances, a surgical visualizationsystem, as disclosed herein, can indicate the different types of tissue(bowel versus rectum) and convey that information to a clinician via animaging system. Moreover, the imaging system can determine andcommunicate the proximity of a surgical device to the select tissue. Insuch instances, the surgical visualization system can provide increasedprocedural efficiency without critical complications.

In another example, a clinician (e.g. a gynecologist) may stay away fromcertain anatomic regions to avoid getting too close to criticalstructures and, thus, the clinician may not remove all of theendometriosis, for example. A surgical visualization system, asdisclosed herein, can enable the gynecologist to mitigate the risk ofgetting too close to the critical structure such that the gynecologistcan get close enough with the surgical device to remove all theendometriosis, which can improve the patient outcomes (democratizingsurgery). Such a system can enable the surgeon to “keep moving” duringthe surgical procedure instead of repeatedly stopping and restarting inorder to identify areas to avoid, especially during the application oftherapeutic energy such as ultrasonic or electrosurgical energy, forexample. In gynecological applications, uterine arteries and ureters areimportant critical structures and the system may be particularly usefulfor hysterectomy and endometriosis procedures given the presentationand/or thickness of tissue involved.

In another example, a clinician may risk dissection of a vessel at alocation that is too proximal and, thus, which can affect blood supplyto a lobe other than the target lobe. Moreover, anatomic differencesfrom patient to patient may lead to dissection of a vessel (e.g. abranch) that affects a different lobe based on the particular patient. Asurgical visualization system, as disclosed herein, can enable theidentification of the correct vessel at the desired location, whichenables the clinician to dissect with appropriate anatomic certainty.For example, the system can confirm that the correct vessel is in thecorrect place and then the clinician can safely divide the vessel.

In another example, a clinician may make multiple dissections beforedissecting at the best location due to uncertainty about the anatomy ofthe vessel. However, it is desirable to dissect in the best location inthe first instance because more dissection can increase the risk ofbleeding. A surgical visualization system, as disclosed herein, canminimize the number of dissections by indicating the correct vessel andthe best location for dissection. Ureters and cardinal ligaments, forexample, are dense and provide unique challenges during dissection. Insuch instances, it can be especially desirable to minimize the number ofdissections.

In another example, a clinician (e.g. a surgical oncologist) removingcancerous tissue may want to know the identification of criticalstructures, localization of the cancer, staging of the cancer, and/or anevaluation of tissue health. Such information is beyond what a cliniciansees with the “naked eye”. A surgical visualization system, as disclosedherein, can determine and/or convey such information to the clinicianintraoperatively to enhance intraoperative decision making and improvesurgical outcomes. In certain instances, the surgical visualizationsystem can be compatible with minimally invasive surgery (MIS), opensurgery, and/or robotic approaches using either an endoscope orexoscope, for example.

In another example, a clinician (e.g. a surgical oncologist) may want toturn off one or more alerts regarding the proximity of a surgical toolto one or more critical structure to avoid being overly conservativeduring a surgical procedure. In other instances, the clinician may wantto receive certain types of alerts, such as haptic feedback (e.g.vibrations/buzzing) to indicate proximity and/or or “no fly zones” tostay sufficiently far away from one or more critical structures. Asurgical visualization system, as disclosed herein, can provideflexibility based on the experience of the clinician and/or desiredaggressiveness of the procedure, for example. In such instances, thesystem provides a balance between “knowing too much” and “knowingenough” to anticipate and avoid critical structures. The surgicalvisualization system can assist in planning the next step(s) during asurgical procedure.

Various aspects of the subject matter described herein are set out inthe following numbered examples.

Example 1. A surgical system for use in a surgical procedure, thesurgical system comprising at least one imaging device and a controlcircuit configured to identify an anatomical organ targeted by thesurgical procedure, generate a virtual three-dimensional (3D) constructof at least a portion of the anatomical organ based on visualizationdata from the at least one imaging device, identify anatomicalstructures relevant to the surgical procedure from the visualizationdata from the at least one imaging device, couple the anatomicalstructures to the virtual 3D construct, and overlay onto the virtual 3Dconstruct a layout plan of the surgical procedure determined based onthe anatomical structures.

Example 2. The surgical system of Example 1, wherein the visualizationdata comprises at least one of structured light data and spectral data.

Example 3. The surgical system of Examples 1 or 2, wherein the layoutplan comprises a starting position determined based on the anatomicalstructures.

Example 4. The surgical system of Examples 1 or 2, wherein the layoutplan comprises a surgical resection path for removing a portion of theanatomical organ, and wherein the surgical resection path is determinedbased on the anatomical structures.

Example 5. The surgical system of Example 4, wherein the control circuitis configured to predict a resulting volume of the anatomical organbased on the surgical resection path.

Example 6. The surgical system of any one of Examples 1-5, whereinidentifying anatomical structures of the anatomical organ comprisesdistinguishing tissue types of the anatomical organ.

Example 7. The surgical system of any one of Examples 1-6, whereinidentifying at least one of the surgical procedure, the anatomical organtype, and the anatomical structures is based on stored data.

Example 8. The surgical system of Example 7, wherein the stored datacomprises at least one of preoperative data, user preference data, anddata from previously performed surgical procedures.

Example 9. A surgical system for use with a surgical instrument in asurgical procedure, the surgical system comprising at least one imagingdevice and a control circuit configured to identify an anatomical organtargeted by the surgical procedure, identify anatomical structuresrelevant to the surgical procedure from visualization data from the atleast one imaging device, and propose surgical resection paths forremoving a portion of the anatomical organ by the surgical instrument,wherein the surgical resection paths are determined based on theanatomical structures.

Example 10. The surgical system of Example 9, wherein the surgicalresection paths comprise different starting points.

Example 11. The surgical system of Examples 9 or 10, wherein thesurgical resection paths yield different organ volumes.

Example 12. The surgical system of any one of Examples 9-11, wherein thesurgical resection paths are overlaid onto a virtual 3D construct of atleast a portion of the anatomical organ.

Example 13. The surgical system of any one of Examples 9-12, wherein thevisualization data comprises at least one of structured light data andspectral data.

Example 14. The surgical system of any one of Examples 9-13, whereinidentifying anatomical structures of the anatomical organ comprisesdistinguishing tissue types of the anatomical organ.

Example 15. The surgical system of any one of Examples 9-14, whereinidentifying at least one of the surgical procedure, the anatomical organtype, and the anatomical structures is based on stored data.

Example 16. The surgical system of Example 15, wherein the stored datacomprises at least one of preoperative data, user preference data, anddata from previously performed surgical procedures.

Example 17. A surgical system for use with a surgical instrument in asurgical procedure, the surgical system comprising at least one imagingdevice and a control circuit configured to identify an anatomical organtargeted by the surgical procedure, identify anatomical structuresrelevant to the surgical procedure from visualization data from the atleast one imaging device, propose a surgical resection path for removinga portion of the anatomical organ by the surgical instrument, whereinthe surgical resection path is determined based on the anatomicalstructures, and modify the surgical resection path during the surgicalprocedure.

Example 18. The surgical system of Example 17, wherein the surgicalresection path is overlaid onto a virtual 3D construct of at least aportion of the anatomical organ.

Example 19. The surgical system of Examples 17 or 18, wherein thevisualization data comprise at least one of structured light data andspectral data.

Example 20. The surgical system of any one of Examples 17-19, whereinidentifying anatomical structures of the anatomical organ comprisesdistinguishing tissue types of the anatomical organ.

While several forms have been illustrated and described, it is not theintention of Applicant to restrict or limit the scope of the appendedclaims to such detail. Numerous modifications, variations, changes,substitutions, combinations, and equivalents to those forms may beimplemented and will occur to those skilled in the art without departingfrom the scope of the present disclosure. Moreover, the structure ofeach element associated with the described forms can be alternativelydescribed as a means for providing the function performed by theelement. Also, where materials are disclosed for certain components,other materials may be used. It is therefore to be understood that theforegoing description and the appended claims are intended to cover allsuch modifications, combinations, and variations as falling within thescope of the disclosed forms. The appended claims are intended to coverall such modifications, variations, changes, substitutions,modifications, and equivalents.

The foregoing detailed description has set forth various forms of thedevices and/or processes via the use of block diagrams, flowcharts,and/or examples. Insofar as such block diagrams, flowcharts, and/orexamples contain one or more functions and/or operations, it will beunderstood by those within the art that each function and/or operationwithin such block diagrams, flowcharts, and/or examples can beimplemented, individually and/or collectively, by a wide range ofhardware, software, firmware, or virtually any combination thereof.Those skilled in the art will recognize that some aspects of the formsdisclosed herein, in whole or in part, can be equivalently implementedin integrated circuits, as one or more computer programs running on oneor more computers (e.g., as one or more programs running on one or morecomputer systems), as one or more programs running on one or moreprocessors (e.g., as one or more programs running on one or moremicroprocessors), as firmware, or as virtually any combination thereof,and that designing the circuitry and/or writing the code for thesoftware and or firmware would be well within the skill of one of skillin the art in light of this disclosure. In addition, those skilled inthe art will appreciate that the mechanisms of the subject matterdescribed herein are capable of being distributed as one or more programproducts in a variety of forms, and that an illustrative form of thesubject matter described herein applies regardless of the particulartype of signal bearing medium used to actually carry out thedistribution.

Instructions used to program logic to perform various disclosed aspectscan be stored within a memory in the system, such as dynamic randomaccess memory (DRAM), cache, flash memory, or other storage.Furthermore, the instructions can be distributed via a network or by wayof other computer readable media. Thus a machine-readable medium mayinclude any mechanism for storing or transmitting information in a formreadable by a machine (e.g., a computer), but is not limited to, floppydiskettes, optical disks, compact disc, read-only memory (CD-ROMs), andmagneto-optical disks, read-only memory (ROMs), random access memory(RAM), erasable programmable read-only memory (EPROM), electricallyerasable programmable read-only memory (EEPROM), magnetic or opticalcards, flash memory, or a tangible, machine-readable storage used in thetransmission of information over the Internet via electrical, optical,acoustical or other forms of propagated signals (e.g., carrier waves,infrared signals, digital signals, etc.). Accordingly, thenon-transitory computer-readable medium includes any type of tangiblemachine-readable medium suitable for storing or transmitting electronicinstructions or information in a form readable by a machine (e.g., acomputer).

As used in any aspect herein, the term “control circuit” may refer to,for example, hardwired circuitry, programmable circuitry (e.g., acomputer processor including one or more individual instructionprocessing cores, processing unit, processor, microcontroller,microcontroller unit, controller, digital signal processor (DSP),programmable logic device (PLD), programmable logic array (PLA), orfield programmable gate array (FPGA)), state machine circuitry, firmwarethat stores instructions executed by programmable circuitry, and anycombination thereof. The control circuit may, collectively orindividually, be embodied as circuitry that forms part of a largersystem, for example, an integrated circuit (IC), an application-specificintegrated circuit (ASIC), a system on-chip (SoC), desktop computers,laptop computers, tablet computers, servers, smart phones, etc.Accordingly, as used herein “control circuit” includes, but is notlimited to, electrical circuitry having at least one discrete electricalcircuit, electrical circuitry having at least one integrated circuit,electrical circuitry having at least one application specific integratedcircuit, electrical circuitry forming a general purpose computing deviceconfigured by a computer program (e.g., a general purpose computerconfigured by a computer program which at least partially carries outprocesses and/or devices described herein, or a microprocessorconfigured by a computer program which at least partially carries outprocesses and/or devices described herein), electrical circuitry forminga memory device (e.g., forms of random access memory), and/or electricalcircuitry forming a communications device (e.g., a modem, communicationsswitch, or optical-electrical equipment). Those having skill in the artwill recognize that the subject matter described herein may beimplemented in an analog or digital fashion or some combination thereof.

As used in any aspect herein, the term “logic” may refer to an app,software, firmware and/or circuitry configured to perform any of theaforementioned operations. Software may be embodied as a softwarepackage, code, instructions, instruction sets and/or data recorded onnon-transitory computer readable storage medium. Firmware may beembodied as code, instructions or instruction sets and/or data that arehard-coded (e.g., nonvolatile) in memory devices.

As used in any aspect herein, the terms “component,” “system,” “module”and the like can refer to a computer-related entity, either hardware, acombination of hardware and software, software, or software inexecution.

As used in any aspect herein, an “algorithm” refers to a self-consistentsequence of steps leading to a desired result, where a “step” refers toa manipulation of physical quantities and/or logic states which may,though need not necessarily, take the form of electrical or magneticsignals capable of being stored, transferred, combined, compared, andotherwise manipulated. It is common usage to refer to these signals asbits, values, elements, symbols, characters, terms, numbers, or thelike. These and similar terms may be associated with the appropriatephysical quantities and are merely convenient labels applied to thesequantities and/or states.

A network may include a packet switched network. The communicationdevices may be capable of communicating with each other using a selectedpacket switched network communications protocol. One examplecommunications protocol may include an Ethernet communications protocolwhich may be capable permitting communication using a TransmissionControl Protocol/Internet Protocol (TCP/IP). The Ethernet protocol maycomply or be compatible with the Ethernet standard published by theInstitute of Electrical and Electronics Engineers (IEEE) titled “IEEE802.3 Standard”, published in December, 2008 and/or later versions ofthis standard. Alternatively or additionally, the communication devicesmay be capable of communicating with each other using an X.25communications protocol. The X.25 communications protocol may comply orbe compatible with a standard promulgated by the InternationalTelecommunication Union-Telecommunication Standardization Sector(ITU-T). Alternatively or additionally, the communication devices may becapable of communicating with each other using a frame relaycommunications protocol. The frame relay communications protocol maycomply or be compatible with a standard promulgated by ConsultativeCommittee for International Telegraph and Telephone (CCITT) and/or theAmerican National Standards Institute (ANSI). Alternatively oradditionally, the transceivers may be capable of communicating with eachother using an Asynchronous Transfer Mode (ATM) communications protocol.The ATM communications protocol may comply or be compatible with an ATMstandard published by the ATM Forum titled “ATM-MPLS NetworkInterworking 2.0” published August 2001, and/or later versions of thisstandard. Of course, different and/or after-developedconnection-oriented network communication protocols are equallycontemplated herein.

Unless specifically stated otherwise as apparent from the foregoingdisclosure, it is appreciated that, throughout the foregoing disclosure,discussions using terms such as “processing,” “computing,”“calculating,” “determining,” “displaying,” or the like, refer to theaction and processes of a computer system, or similar electroniccomputing device, that manipulates and transforms data represented asphysical (electronic) quantities within the computer system's registersand memories into other data similarly represented as physicalquantities within the computer system memories or registers or othersuch information storage, transmission or display devices.

One or more components may be referred to herein as “configured to,”“configurable to,” “operable/operative to,” “adapted/adaptable,” “ableto,” “conformable/conformed to,” etc. Those skilled in the art willrecognize that “configured to” can generally encompass active-statecomponents and/or inactive-state components and/or standby-statecomponents, unless context requires otherwise.

The terms “proximal” and “distal” are used herein with reference to aclinician manipulating the handle portion of the surgical instrument.The term “proximal” refers to the portion closest to the clinician andthe term “distal” refers to the portion located away from the clinician.It will be further appreciated that, for convenience and clarity,spatial terms such as “vertical”, “horizontal”, “up”, and “down” may beused herein with respect to the drawings. However, surgical instrumentsare used in many orientations and positions, and these terms are notintended to be limiting and/or absolute.

Those skilled in the art will recognize that, in general, terms usedherein, and especially in the appended claims (e.g., bodies of theappended claims) are generally intended as “open” terms (e.g., the term“including” should be interpreted as “including but not limited to,” theterm “having” should be interpreted as “having at least,” the term“includes” should be interpreted as “includes but is not limited to,”etc.). It will be further understood by those within the art that if aspecific number of an introduced claim recitation is intended, such anintent will be explicitly recited in the claim, and in the absence ofsuch recitation no such intent is present. For example, as an aid tounderstanding, the following appended claims may contain usage of theintroductory phrases “at least one” and “one or more” to introduce claimrecitations. However, the use of such phrases should not be construed toimply that the introduction of a claim recitation by the indefinitearticles “a” or “an” limits any particular claim containing suchintroduced claim recitation to claims containing only one suchrecitation, even when the same claim includes the introductory phrases“one or more” or “at least one” and indefinite articles such as “a” or“an” (e.g., “a” and/or “an” should typically be interpreted to mean “atleast one” or “one or more”); the same holds true for the use ofdefinite articles used to introduce claim recitations.

In addition, even if a specific number of an introduced claim recitationis explicitly recited, those skilled in the art will recognize that suchrecitation should typically be interpreted to mean at least the recitednumber (e.g., the bare recitation of “two recitations,” without othermodifiers, typically means at least two recitations, or two or morerecitations). Furthermore, in those instances where a conventionanalogous to “at least one of A, B, and C, etc.” is used, in generalsuch a construction is intended in the sense one having skill in the artwould understand the convention (e.g., “a system having at least one ofA, B, and C” would include but not be limited to systems that have Aalone, B alone, C alone, A and B together, A and C together, B and Ctogether, and/or A, B, and C together, etc.). In those instances where aconvention analogous to “at least one of A, B, or C, etc.” is used, ingeneral such a construction is intended in the sense one having skill inthe art would understand the convention (e.g., “a system having at leastone of A, B, or C” would include but not be limited to systems that haveA alone, B alone, C alone, A and B together, A and C together, B and Ctogether, and/or A, B, and C together, etc.). It will be furtherunderstood by those within the art that typically a disjunctive wordand/or phrase presenting two or more alternative terms, whether in thedescription, claims, or drawings, should be understood to contemplatethe possibilities of including one of the terms, either of the terms, orboth terms unless context dictates otherwise. For example, the phrase “Aor B” will be typically understood to include the possibilities of “A”or “B” or “A and B.”

With respect to the appended claims, those skilled in the art willappreciate that recited operations therein may generally be performed inany order. Also, although various operational flow diagrams arepresented in a sequence(s), it should be understood that the variousoperations may be performed in other orders than those which areillustrated, or may be performed concurrently. Examples of suchalternate orderings may include overlapping, interleaved, interrupted,reordered, incremental, preparatory, supplemental, simultaneous,reverse, or other variant orderings, unless context dictates otherwise.Furthermore, terms like “responsive to,” “related to,” or otherpast-tense adjectives are generally not intended to exclude suchvariants, unless context dictates otherwise.

It is worthy to note that any reference to “one aspect,” “an aspect,”“an exemplification,” “one exemplification,” and the like means that aparticular feature, structure, or characteristic described in connectionwith the aspect is included in at least one aspect. Thus, appearances ofthe phrases “in one aspect,” “in an aspect,” “in an exemplification,”and “in one exemplification” in various places throughout thespecification are not necessarily all referring to the same aspect.Furthermore, the particular features, structures or characteristics maybe combined in any suitable manner in one or more aspects.

Any patent application, patent, non-patent publication, or otherdisclosure material referred to in this specification and/or listed inany Application Data Sheet is incorporated by reference herein, to theextent that the incorporated materials is not inconsistent herewith. Assuch, and to the extent necessary, the disclosure as explicitly setforth herein supersedes any conflicting material incorporated herein byreference. Any material, or portion thereof, that is said to beincorporated by reference herein, but which conflicts with existingdefinitions, statements, or other disclosure material set forth hereinwill only be incorporated to the extent that no conflict arises betweenthat incorporated material and the existing disclosure material.

In summary, numerous benefits have been described which result fromemploying the concepts described herein. The foregoing description ofthe one or more forms has been presented for purposes of illustrationand description. It is not intended to be exhaustive or limiting to theprecise form disclosed. Modifications or variations are possible inlight of the above teachings. The one or more forms were chosen anddescribed in order to illustrate principles and practical application tothereby enable one of ordinary skill in the art to utilize the variousforms and with various modifications as are suited to the particular usecontemplated. It is intended that the claims submitted herewith definethe overall scope.

What is claimed is:
 1. A surgical visualization system comprising: aplurality of light sources; at least one optical sensor; at least onedisplay device; and a controller comprising a processor and a memoryunit, wherein the memory unit is configured to store instructions that,when executed by the processer, cause the controller to: control atleast one of the plurality of light sources to illuminate a tissue in afirst manner by projecting a pattern of light onto a surface of thetissue; control the at least one optical sensor to receive first lightreflected by the surface of the tissue when illuminated in the firstmanner; calculate first imaging data of a three-dimensional image of oneor more surface features of the tissue based on the first lightreflected by the surface of the tissue when illuminated in the firstmanner; control at least one of the plurality of light sources toilluminate the tissue in a second manner by illuminating the tissue witha plurality of emitted light waves, wherein each of the plurality ofemitted light waves has a unique light spectrum, and wherein at leastone of the plurality of emitted light waves has a light spectrumconfigured based on a spectral signature of one or more subsurfacecritical anatomic structures of the tissue; control the at least oneoptical sensor to receive second light from the tissue when illuminatedin the second manner; calculate second imaging data of the one or moresubsurface critical anatomic structures of the tissue based on thesecond light received by the at least one optical sensor; and display acombination of the first imaging data and the second imaging data on theat least one display device.
 2. The surgical visualization system ofclaim 1, wherein the instructions that, when executed by the processor,cause the controller to control at least one of the plurality of lightsources to illuminate a tissue in a first manner by projecting a patternof light onto the surface of the tissue comprise instructions that, whenexecuted by the processor, cause the controller to control at least oneof the plurality of light sources to project at least one of a patternof grid lines, stripes, or dots onto the surface of the tissue.
 3. Thesurgical visualization system of claim 1, wherein the unique lightspectrum of each of the plurality of emitted light waves comprises avisible light spectrum, a near infra red light spectrum, or a short waveinfra red light spectrum.
 4. The surgical visualization system of claim1, wherein the unique light spectrum of each of the plurality of emittedlight waves comprises a red light spectrum, a green light spectrum, or ablue light spectrum.
 5. The surgical visualization system of claim 1,wherein the second imaging data comprise hyperspectral data.
 6. Thesurgical visualization system of claim 1, wherein the second imagingdata comprise critical anatomic structure subsurface location data. 7.The surgical visualization system of claim 1, wherein the second imagingdata comprise critical anatomic structure compositional data.
 8. Thesurgical visualization system of claim 1, wherein the second imagingdata comprise critical anatomic structure identification data.
 9. Thesurgical visualization system of claim 1, wherein the combination of thefirst imaging data and the second imaging data comprise data of an imagecombining the three-dimensional image of the one or more surfacefeatures of the tissue and the critical anatomic structure.
 10. A methodof visualizing a tissue, comprising: illuminating, by at least one of aplurality of light sources, a tissue in a first manner by projecting apattern of light onto a surface of the tissue; receiving, by at leastone optical sensor, light reflected from the surface of the tissueilluminated in the first manner; calculating, by a processor, firstimaging data based on the light reflected from the surface of the tissueilluminated in the first manner, wherein the first imaging data comprisea three-dimensional image of one or more surface features of the tissueilluminated in the first manner; illuminating, by at least one of theplurality of light sources, the tissue in a second manner byilluminating the tissue with a plurality of emitted light waves, whereineach of the plurality of emitted light waves has a unique lightspectrum, and wherein at least one of the plurality of emitted lightwaves has a light spectrum configured based on a spectral signature ofone or more subsurface critical anatomic structures of the tissue;receiving, by at least one optical sensor, light reflected from thetissue illuminated in the second manner; calculating, by the processor,second imaging data based on the light reflected from the tissueilluminated in the second manner, wherein the second imaging datacomprise an image of the one or more subsurface critical anatomicstructures of the tissue illuminated in the second manner; anddisplaying, on at least one display device, a combination of the firstimaging data and the second imaging data.
 11. The method of claim 10,wherein illuminating, by at least one of a plurality of light sources, atissue in a first manner by projecting a pattern of light onto thesurface of the tissue comprises illuminating, by at least one of theplurality of light sources, the tissue by projecting at least one of apattern of grid lines, stripe, or dots onto the surface of the tissue.12. The method of claim 10, wherein illuminating the tissue with aplurality of emitted light waves comprises illuminating the tissue witha plurality of emitted light waves, each emitted light wave having avisible light spectrum, a near infra red light spectrum, or a short waveinfra red light spectrum.
 13. The method of claim 10, whereinilluminating the tissue with a plurality of emitted light wavescomprises illuminating the tissue with a plurality of emitted lightwaves, each emitted light wave having a red light spectrum, a greenlight spectrum, or a blue light spectrum.
 14. The method of claim 10,wherein calculating, by the processor, second imaging data based on thelight reflected from the tissue illuminated in the second mannercomprises calculating, by the processor, hyperspectral data.
 15. Themethod of claim 10, wherein calculating, by the processor, secondimaging data based on the light reflected from the tissue illuminated inthe second manner comprises calculating, by the processor, criticalanatomic structure subsurface location data.
 16. The method of claim 10,wherein calculating, by the processor, second imaging data based on thelight reflected from the tissue illuminated in the second mannercomprises calculating, by the processor, critical anatomic structurecompositional data.
 17. The method of claim 10, wherein calculating, bythe processor, second imaging data based on the light reflected from thetissue illuminated in the second manner comprises calculating, by theprocessor, critical anatomic structure identification data.
 18. Themethod of claim 10, displaying, on at least one display device, acombination of the first imaging data and the second imaging datacomprises displaying, on the at least one display device, an imagecombining the three-dimensional image of the one or more surfacefeatures of the tissue and the image of the one or more subsurfacecritical anatomic structures.